Sutter Medicare Direct

All doctors and advanced practice clinicians who practice at Sutter Bay Medical Foundation or Sutter Valley Medical Foundation — including Palo Alto Medical Foundation, Sutter East Bay Medical Foundation, Sutter Gould Medical Foundation, Sutter Medical Foundation, and Sutter Pacific Medical Foundation —  are working with Sutter Medicare Direct as ACO professionals.

Patients with Original Medicare have a card that is red, white, and blue that says “Medicare Health Insurance” at the top. This includes patients who are also covered by Medicare Supplement Insurance, also known as Medigap, which is secondary coverage offered by private health insurance companies.

The Medicare Shared Savings Program (MSSP) is a well-established program within Original Medicare designed to improve the health and wellness of patients. MSSP encourages doctors, hospitals and other providers to collaborate in delivering coordinated, high-quality care to assigned patients.

An Accountable Care Organization (ACO) is a group of doctors, hospitals and other providers, who collaborate to give coordinated high-quality care to their Original Medicare patients. Sutter Health’s ACO is called Sutter Medicare Direct.

The goal of an ACO’s coordinated care is to ensure that assigned patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. ACOs have agreements with Medicare to be financially accountable for the quality, cost and experience of care patients receive.

No. Sutter Medicare Direct is not an HMO, a health plan or an insurance company. It is an ACO participating in MSSP and part of the Sutter Health health system.

No. This will not change what you pay out-of-pocket, such as any monthly premiums for Medicare Part B (Medical Insurance) or Medicare Part D (Prescription Drug Coverage), or your coinsurance for a doctor’s visit.

Yes. You continue to have the freedom to go to any doctor, hospital or other healthcare providers that accept Original Medicare.

No. There is no change to your referrals and prior authorization is only needed if Original Medicare requires one (e.g., durable medical equipment such as power wheelchairs).

No. This program does not change the relationship between you and your doctor. There are no networks or prior authorizations unless Original Medicare requires one. Sutter Medicare Direct simply works behind the scenes to coordinate otherwise siloed care with a focus on making care more efficient, eliminating unnecessary services and encouraging prevention.

The Medicare Shared Savings Program allows Sutter team members to provide essential support services to your doctor, such as new tools, resources, or information — all with a focus on helping them coordinate and manage your care. For example, Sutter team members will contact patients following an unplanned hospital admission to help them schedule a primary care follow-up visit and help facilitate a smooth transition from hospital to home and avoid preventable hospital readmissions in the future.

Yes. When you choose a doctor or clinician who participates in an ACO, they’ll help you get the right care at the right time. You can visit Medicare.gov and log into (or create) your secure Medicare account to choose a primary care doctor. You can learn more in this Medicare fact sheet.

To help patients get access to the right care at the right time and in the right place, MSSP allows ACOs to offer patients access to services that are not typically covered by Original Medicare including:

• Skilled nursing facility (SNF) care for patients, even if they haven’t stayed in a hospital for three days first, which is usually a Medicare requirement. To qualify for this benefit, Sutter Medicare Direct patients must have an identified SNF need and meet certain eligibility criteria.
• Telehealth services for patients to receive certain services from the comfort of their home or other settings and communicate in real time with primary care clinicians or specialists.

No. Medicare assigns individual patients to an ACO based on specific eligibility requirements and past claims data.

Medicare permits data sharing for the purpose of improving or preserving quality, promoting preventive care, enhancing patient satisfaction, and making care more affordable. This includes Medicare claims data and anonymous patient satisfaction survey results shared with Sutter Medicare Direct and doctors providing care.

You have the right to decline claims data sharing. You can do so by modifying your data sharing preferences by calling 1-800-MEDICARE (800-633-4227; TTY users may call 877-486-2048). Tell the representative that your healthcare provider is part of an ACO and you don’t want Medicare to share your healthcare information. Please note: Medicare will still engage in limited data sharing with Sutter Medicare Direct for quality improvement.

Learn more about the MSSP Program here or call Medicare at 1-800-MEDICARE 800-633-4227; TTY users may call 877-486-2048.