Value-Based or Fee-For-Service—Pick One

Most organizations make the mistake of forcing their primes to live in two worlds at once.       There’s the Medicare Advantage “value-based” world, in which relationship, data-collection, and cost control are key.       And there’s the “fee-for-service” world, where the primes are being asked to feed your specialists so they can keep generating high-dollar procedures.       Either world is very lucrative, though generating data-based revenue is much, much cheaper....

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Don’t Fear Losses

So many of the challenges of the organizations I consult with could be fixed with a little clarity.       Health systems put a lot of pressure on their primes to control costs. They alienate their Medicare Advantage enrollees with that pressure as well.       Most “stop-loss” insurance for Medicare Advantage contracts pay 90% of losses after a $10,000 deductible, and 100% after the losses hit 100k. There’s some variability in benefits...

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Stop Paying Third Parties to See Your Medicare Advantage Patients, Pay Your Primes Instead

I freelance for a service that sends docs into the homes of Medicare Advantage patients to collect data for their yearly visit.       They charge plans and organizations $500 or more to obtain the data of patients who would otherwise not be seen.       Try paying that to your primes instead.       Give them a substantial bonus if they get more than 95% of their patients in to be...

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Compliance Week—What You Can Learn From The College Admission Scandal

The FBI was tipped off to the college admission scandal by a trader who was being investigated for insider trading.     He hoped by dropping a dime on someone, anyone he would gain favorable treatment.     The storm he touched off pretty much guarantees those convicted will find no mercy.     Who inside your organization knows about inappropriate data submission?       What would happen to them if they were arrested?...

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Grow Your Panel With Personal Referrals

I once met the leading salesman for all of GM.     He was a short, fat, dumpy guy—the exact opposite of a slick car salesman.     But he personally had sold more cars for the company than anyone else—ever.     He was teaching the secret of sales and I wanted to know how much was applicable to growing the Medicare Advantage panels of myself and my partners.     Turned out, it...

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Be Transparent or Don’t Risk-Share At All

If you’re going to risk-share with your primes, be transparent.     I’ve recently been contacted in a number of cases where the employed clinicians have been contracted to financially risk-share with their employers, only to have the employers cook the numbers and keep some of their revenue.     In each case, the promised risk-share was murky with no regular sharing of data between the employers and the clinicians.     Why anyone in...

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Mr. Biondo

Every few months I like to re-post my first blog entry and remind myself why we’re doing what we do. Mr. Biondo is a real person and a good man. He gave me permission to tell his story if I thought it might help someone. When I first met Mr. Biondo he was not at all well.  He had lost a leg through misfortune. The bed sores from his outdated mobility equipment had let infection...

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How To Send The Message To Your Medical Staff That Your Serious About Your Risk-Sharing Partnership

An increasing number of health systems are getting sued by their medical staff for not coming through with promised risk-sharing compensation. Since risk-sharing comp is more “data-based,” it’s more susceptible to manipulation, both real and percieved. If you’re going to financially risk-share with your medical staff, you better make the rules clear and the financial reporting regular and easy to understand. I would also consider engaging an outside auditor to review and report on your...

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Are You or Your Insurance Partners Buying Enrollment

According to a little gem in this report, you might be.     Enrollment growth for Medicare Advantage in 2018 was strong but out of pocket costs and monthly premiums for beneficiaries dropped across the board.     This suggests that the growth isn’t as robust as it seems.     As an insurer, health system or clinician you must make sure you’re generating real value for your Medicare Advantage patients or they may not...

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Create Your Own Metrics

There is enough money in the Medicare Advantage revenue stream to pay your clinicians for meeting metrics that improve the overall contract’s success—even if you don’t want to risk-share with them directly.     The best I saw was a $10 per patient bonus for meeting this measure for 12 straight months:     Have 95% of the patients on your panel completed an annual wellness visit in the past 12 months?     Simple,...

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