A Novel Approach to Success

  An executive recently contacted me asking how to transition their medical staff to a financial-risk compensation model which included a downside for the clinician.     Here’s what I told her:   Create a model you are comfortable with and that meets your goals—define the population, the split, the frequency of reconciliation, etc… Invest in the infrastructure required for regular financial reporting in an understandable manner as we’ve discussed so frequently in this space....

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New MAO Insures is Your Opportunity to Innovate

    As new insurers enter the Medicare Advantage market, that’s you’re opportunity for taking advantage the many opportunities we discuss in these pages.       Shop around for your own reinsurance coverage (don’t take theirs at an initial low rate, they’ll just jack it up later when they’ve become established). Ensure that you have vendor options for carve-ins like home health and hospice. Enshrine escalators into your monthly stipend payments so as you...

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Passing the Costs Upwards

  Your Medicare Advantage insurance partners are doing everything they can in their contracts to push care costs down to you.     You can be certain they’re altering your contracts, debiting you for expenses you’re not responsible for and hoping you won’t notice, they’re even taking kickbacks and giving exclusive rights to certain vendors to service your patients—and charging the higher-than-market rates to you.     This is all cynical, I know. but it’s...

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Stop-Loss Opportunity

  If your organization takes downside financial risk from your Medicare Advantage insurer (and if you don’t you soon will), then you have some sort of line item for “stop-loss insurance” to protect you against an adverse experience.       Stop-loss insurance covers you in case a patient’s care costs exceed a certain threshold—it keeps you in the game when you suddenly have an unusually large number of patients pop up with health problems....

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Protect Yourself Against Whistleblowers

    Your biggest risk from whistleblowers is the primes in your organization.   They’re collecting information that they will use to file a qui tam action in case they get terminated or as a nest egg when they decide to quit.   These suits are usually settled without admission of wrongdoing but they can be pricey.   Your primes are being targeted by False Claim Act attorneys over social media for qui tam actions.  ...

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Why Aren’t You Doing Well With Your Dual-Eligible Patients

    The capitation for “Dual-Eligible” or Medicare-Medicaid patients under Medicare Advantage can be as much as 30% higher than that of “regular” patients.     So why aren’t you doing better with them?     They’re not “sticky.”     They don’t stay with their PCP, often changing after only a couple of months.     They’ll also more vulnerable to illegal inducements to switch, often accepting payments to change primes or even insurers....

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Check Your Contracts for Carve-In Rates

      “Carve-ins” are benefits offered to your patients the cost of which are included in your capitation.     If you’re financially risk-sharing, that means part of the costs of those carve-ins are are coming out of your pocket.     Yet you have no control over how much you pay for those benefits, your Medicare Advantage insurance partner does. And they have many other objectives other than maximizing the value of the...

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Having Your Clinicians Start Taking Downside Risk? You Must Do This First!

When organizations tell their clinicians they’re going to have to take downside financial risk through medicare advantage, they do just that, they emphasize the downside.   They don’t do a good job telling their staff about the possible upside and even more importantly, how to best achieve a benefit.   In fact, when I’m contacted by a health system in trouble with their medicare advantage contract, I always find that that they were flippant when...

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How Transparent Are You?

    If your organization is being forced into insurance contracts with downside financial risk, you’re going to be tempted to pass at least some of that down to your clinicians.     And if you do that transparency is essential.     You must be candid with your clinicians about the rules of these contracts.     You must be clear as to what behaviors from them are desirable as you try to make...

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