From Tom's Desk

The New York Times, the "Velvet Rope", and You

This week, as part of its ongoing series about the “velvet rope economy,” the New York Times published a feature on the ultra-high-end medical service industry. The details of catering to the wealthiest are about what you would expect.

In the article, there’s much discussion from physicians about how their personalized care coordination justify five figure retainers, how they simply could not provide the same level service in their former practices, how providing this level of care is so rarified that only clinicians from “Ivies or Ivy League-esque schools need apply.”

Reading it left me quite sad.  Most of these clinicians are driven to serve in the highest tradition of the profession.  Yet, save for being “asset managers” for their few uber-wealthy clients, they can see no other way they could practice medicine to their own satisfaction, sustainably, for the population at large. You can hear the discouragement in their own words. It's a cry for help.

Too bad they didn’t ask us.  

Every service they provide in their high-dollar retainer practice with such satisfaction, my partners and I provided in ours. For more than twenty years. And we took all comers.

Need to get in today?—come on by.

Need to see a cardiologist right now?—let me pick up the phone and call John’s cell. He’ll see you personally. Today.

Need to call about a symptom in the middle of the night?—Here's my number.

We didn’t burn out. We were fully engaged and our compensation was every bit as good as described in the article.

Better even.

All because of a couple of reasonable risk-sharing contracts.

And care systems we generalized to our entire patient population.

You don’t have to cater to the very rich to get the life you want.

Get a reasonable gain-share contract, recruit 300-500 patients and go for it.

At the very least you won’t find yourself crying for help in the pages of the New York Times.

You Should Know...

The GAO Looks at Disenrollment Rates

This week the Federal General Accounting Office (GAO) released it’s Congressionally-requested review of the patients  in poor health disenrolling from Medicare Advantage plans. The report looked at a specific number of plans with higher-than-average disenrollment of these sicker-than-average beneficiaries and tried to identify the reasons behind them leaving their plans.


The GAO found that, for nearly twenty percent of the plans examined, patients were leaving, not due to cost concerns, but due to lack of available preferred providers or other care access issues.


The resulting recommendation, which CMS has accepted, is to include monitoring of such disenrollment rates as a part of the oversight of these plans.


These types of reports and recommendations are usually the first step in the journey that eventually leads to overt regulation and payment changes.  This particular recommendation may be the first inkling of governmental push back against the “narrow network” strategy of top-down cost control through limiting the number of clinicians who are allowed to participate in a given contract.


Hard won and intimate personal experience has taught me that the greater the financial risk-sharing with the primes, the less narrow networks are required—or indeed desired. Primes with skin in the game will narrow their own network to only those specialists and ancillary providers who are at the top of their game.  This organic, “bottom-up” cost control is highly effective, patient friendly and is the key to preventing the type of disenrollment this GAO report is addressing.


Insurers who understand this fact, can get ahead of the regulatory and payments changes that will inevitably follow the GAOs recommendation—and those that do certainly won’t have to worry about disenrollment rates in their own plans.

High-Value Insight

Protien-Calorie Malnutrition

Protein calorie malnutrition(PCM) (E44.1 mild, E44.0 moderate, E43 severe, E46 non-specific or associated with hypoalbuminemia) is a common finding in chronically-ill patients. And it’s associated with an enormous increase in your risk score and subsequent capitation. Identifying and treating this condition is a key strategy toward keeping your pool solvent when sickness strikes.


Unlike, say atherosclerosis of the aorta or chronic bronchitis, there is no fixed definition as to when this code may be submitted.  The definition is so vague and the payoff so great that I advise you not to use them in absence of a black and white laboratory finding such as a low albumin, total protein or serum transferrin. 


That’s really important, as these types of vague codes are going to be increasingly targeted as aggressive compliance systems begin to take hold. For recovery auditors, validating these codes represents one of the greatest potential financial returns on their organization’s time.


Any time a complete metabolic profile is ordered, you should get in the habit of paying close attention to the albumin and total protein.  If one or both are low, submitting code E46 is clearly in order, as an addendum to the original visit once the condition is appropriately addressed.  Low transferrin incidentally found during anemia evaluations is also an accepted marker of PCM and can be safely used as justification for the diagnosis.  Use the different mild, moderate, or severe codes noted above based on the lab result and your documented subjective assessment of the degree of abnormality. 


This extra effort will improve the health of your patient, as PCM can be linked to an increased risk of falls. Once the code is incorporated into your RAF score, it will also mean up to a 60% boost in your monthly capitation for a whole year.


Just make sure you document it carefully and only when it actually exists.

Q&A with Dr. Tom

How do you handle referral requests for chiropractic care?


I give the patient whatever they want.


Love it or hate it, access to chiropractic is a mandated benefit and your patients know it.  Whether you’re of the opinion that it’s quackery or a key part of overall health, some of your patient’s are going to ask about chiropractic services.  And that makes your local chiropractors your professional collaborators.


There’s something about laying on of hands that gives you street cred. The “healing touch,” my attendings used to call it.  Imagine how much credibility performing full body adjustment is going to give your chiropractor, especially to a patient already pre-disposed to respecting her opinions.


In the middle of their adjustment, do you want that chiropractor bad mouthing you or do you want her to sing your praises?  Seamlessly refer patients as they request and you’ll definitely get the latter.  Your willingness to cooperate will standout, especially in contrast to your fellow providers who may not be as wise as you.


I know, I know.  Chiropractors often do practice outright quackery and sell supplements with both significant profit margins and unsubstantiated benefits. 


That doesn’t change the fact that they exist and Medicare recognizes their services. But you know which ones are dangerous and which can be therapeutic—you can direct your patients to avoid the former and embrace the latter.


Chiropractors are best managed through a collaboration that strengthens the relationship with your patient.  The cost to your pool is minimal, usually double digits per visit.  Think of it as the price of building credibility with your patients. 


That way, you can intervene effectively when they ask you about any treatment that could truly be dangerous.

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