From Tom's Desk

From the Journal of Managed Care.

Healthcare services funded through a risk-adjusted, capitated model generated better results using fewer resources, while spending less money than a fee-for-service model over three years in matched populations.

The study, performed by Optum, looked at two physician groups in Portland, Oregon for a three year period. It is the best designed, highest powered study of it's type I've yet seen; the only real criticism is the risk of bias from the funding source.

The risk-adjusted group had a statistically significant 6% higher survival rate, with 11% less emergency room utilization and 12% lower inpatient utilization, for a savings of $2M per 1000 enrollees.

This data, biased though the sponsor might be, supports the idea that the Federal government can off-load financial risk for its healthcare commitments to a private insurer, use a risk-based design to fund the delivery of that healthcare and have that insurer generate a sustainable profit while improving outcomes all round.

No surprise to me, I lived it for 15 years. I saw it first hand.

How did was the insurer able to do it?

By giving their contracted delivery organizations a financial interest in the net performance of the contract. Organizations which, in turn, were willing to align their clinician's interests with similar financial incentives.

Far from withholding care to make a buck, the clinicians were empowered to unlock their critical problem-solving skills to serve their patients...and look at the result.

Of course, one study funded by an organization with potential bias isn't a game changer, no matter how statistically powerful and well designed...even with the confirmation bias of my decades of personal experience.

But it should make you think.

What could you do under similar circumstances?

You Should Know...

Merritt Hawkins just released it's 2017 physician accessibility survey. The survey is conducted to mimic the experience of a new patient seeking the services of a Family Physician or one of several specialties across 15 large and 15 medium-sized metropolitan service areas. MH has performed this survey using matched statistical methods, periodically, since 2004.

The results?

Wait times for new patient appointments are up and Medicare and Medicaid participation are down—especially for Family Physicians. All of these measures are at the top of their trends. In some markets the number of Family Physicians taking new Medicare patients are as low as 40%.

This is an enormous policy problem for our government...and, an enormous opportunity for you, the clinical innovator.

Figure out how to serve these populations sustainably and scale your ideas.

Exponential growth awaits.

High-Value Insight

One of the sources of risk-adjustment diagnostic code extraction for your Medicare Advantage patients is the Minimum Data Set (MDS) from your patients in skilled nursing facilities and nursing homes. This information is required to be transmitted by the nursing facility quarterly and eventually will make its way into your patient's RAF score calculation.

The source of information for the MDS?

Clinicians. The facility simply copies the diagnoses from your documentation.

Yet somehow, I continue to find errors on my patient's MDS submissions that are simply astonishing.

Errors of both commission and omission.

What should you do?

During your nursing home patients' admission or annual physicals, address and document every chronic disease appropriate for that patient and tie each diagnosis to a treatment plan. Your facility will, as a matter or course, include these diagnoses in their quarterly MDS submission...where it will eventually be included in your RAF score.

Beware, the MDS is also an area ripe for the picking by recovery auditors looking to find inadequately documented risk scores, as resolved problems can find their way on the diagnoses lists and continue to be submitted for years after they have resolved.

As part of your yearly assessment, include a review of the MDS for accuracy. You should be able to find it as a list of diagnoses somewhere on each physician order sheet. Does your facility use an electronic record? Ask your nurse to pull up the MDS on the monitor, the diagnoses will be right there. If they are inaccurate, your nurse should be able to correct the documentation on the spot. Taking a moment once a year to make sure the diagnoses on the MDS are correct can spare yourself the agony of a clawback five years from now.

Currently, for risk adjustment calculation purposes, your Medicare Advantage insurer only needs to see those diagnostic codes once yearly. But the system outlined above will serve as a failsafe to make sure your patient's data does get submitted, and submitted more protection against a poor memory or cluttered electronic health record.

Q&A with Doctor Tom

An excellent hospice service is such a key to generating value under a risk-based health insurance plan. What's the best way to find one to partner with?

Hospice services can help limit end-of-life care costs while dramatically boosting the value of care provided to the patient and their family—but only an excellent hospice will do so. I know from both professional and personal experience

The newly required star ratings can help, but also can be gamed. Create your own ratings. Be a secret shopper.

Take a list of the hospices you might work with and early on a Saturday evening, pose as a potential client. Call their number and inquire about services.

“A relative may be ready for your services, can you help?”

The very best hospices will respond with taking your number and immediately putting you through to an intake professional, such as a nurse.

From there, you can identify yourself as a clinician and ask about services, response times, etc.

If you get any other response, a request for insurance information, or being placed on hold with no explanation, just hang up and cross that one off your list. You've saved yourself—and your patients—a world of problems.

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