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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Personal Training for Your System’s Success

Keep a personal trainer on retainer so your primes can use them for their patients who are motivated to use the extra help.   What’s the most powerful predictor of healthcare costs?   It’s frailty.   How do you cure frailty?   Exercise. Resistance exercise.   Can you cure frailty in everyone?   No. You can only cure it in someone who’s motivated.   But with Medicare Advantage the ROI on a single frail person who’s...

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Continuity of Care

The health systems I work with who have the highest performing Medicare Advantage plans all have one thing in common.       When their PCP decides a specialist visit is needed the patient is able to make that appointment on the way out the door—with the PCP’s staff coordinating the service.       And if the specialist appointment can’t be had in a timely basis, there’s a system in place in the office...

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Incubate

I got a solid 88% on my first anatomy test.     My good friend got a 99.     Soon I found he could no longer meet for our early morning study sessions—nor could he tell me why.     Seems that one of the professors was under the impression that a high score on the first anatomy test correlated with clinical excellence—how he came to this conclusion is unclear, but it was the...

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Scribes for Primes are More than Cost-Effective—They’re Essential.

Under a data-based contract such as Medicare Advantage, your PCP’s time is the most valuable real estate your system can build on—are you treating it that way?     In my professional work, I’ve noticed the trend is moving away from risk-sharing with primes under their Medicare Advantage contracts.     I’m told this decision is based on the idea that Medicare Advantage is a pure data play.     Collect the data, book the...

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Success Codes—Patient Condition Counts, The Sun Tzu Edition

Last week, we distilled down CMS’s most recent 60-page proposal to revise the risk-coding system down to a couple of paragraphs.     Today we look at how to take that information and get ahead of the curve?     The first step is to back to your Sun Tzu in The Art of War—“They who try to control everything, controls nothing.”       A given patient will be awarded a higher RAF score if...

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Success Codes—Patient Condition Count Edition

You can be forgiven if you missed it among all your holiday frivolity, but CMS released a proposal for the latest risk-code update.  It’s significant.   And I read it so you don’t have to.   The bottom line?   If adopted, pay special attention to collecting all the HCC groups for your dual-eligible patients—that’s where the low hanging fruit is.   Details: There are two proposed models under discussion—one that includes two additional conditions...

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The Greatest Threat to Your Medicare Advantage Revenue: Not Compliance Enforcement But Rather Competitive Bidding

Up to the last month, I’ve been predicting that it will be a “compliance backlash” against all the fraudulent risk-coding and other data submissions that will greatly reduce the revenue of Medicare Advantage organizations (MAOs)—reducing the profitability of high-margin plans and sinking all others.     Experience teaches that I’m right about the system pushing back against the excessive revenue harvesting, I may, however, have been mistaken about the catalyst.     There has been...

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A Holiday Gift

In honor of the holidays, I’m going to share with you the secret to excellent net Medicare Advantage performance.   One of my clients just found out that her use of this knowledge generated more than $600k in net revenue for her this year—and I’m offering it here to you for free.   Spread it around. Use it to succeed. Look like a genius. You don’t even have to attribute it to me.   Grow...

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The Environment for Medicare Advantage is About to Change—Will You Survive, Thrive or Fail?

As I review Medicare Advantage systems one thing has been popping up over-and-over again.   They’re all heavily optimized for the current environment.   By that, I mean an environment that is over-funded with little compliance enforcement. One in which market share is desirable above all else.   These systems are extremely profitable—and growing more so as their managers further optimize their operations.   They’re so optimized that when condition change—as they soon must—the degradation in...

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