From Tom's Desk


Canary in the Coal Mine


On June 25th, CMS was expected to release 2014 Medicare Advantage encounter data.


It cancelled  at the last minute due to “data problems.”


Conspiracy theories are abounding—mostly about CMS using the extra time to massage the data to protect the interests of the big insurers.


I doubt that’s true. It’s a lot of data, challenging to process and present.


But no one is talking about the enormous red flag this represents.


This is exactly the type of data that’s going to be used to determine the huge payment swings under the MACRA/MIPS program beginning in 2019.


Only MACRA/MIPS involves more than twice as many patients, with ever-changing metrics and parameters.


You’re investing huge amounts of capital hoping to avoid a loss of revenue but the system you’re depending to analyze your efforts on can’t even manage to process a three year old data set with, in comparison, much more limited parameters.


CMS has already had to delay or change payments in other quality programs due to inability to collect and analyze the data. Not to mention delaying ICD-10 three times due to their IT infrastructure's inability to test end-to-end.

With billions on the line and a momentum that's impossible to stop, MACRA/MIPS is  going to be train wreck of epic proportions. Absent any statutory relief, you're going to have to accept changes in your cashflow that have basically been decided at random--without respect to any "quality" changes you've made.  No way CMS is going to be prepared to crunch the numbers to reflect reality of your efforts.  No. Way.


Insurer, organization or individual clinician, if you’re “all in” on MACRA/MIPS, you better have a plan B to cover your expenses.

Come Q1 2019 there's a good chance your cashflow won't.

You Should Know...

Medicare D Danger

If a beneficiary enrolled in a Medicare Advantage plan changes their part D plan, they will automatically disenroll from Medicare Advantage and into traditional medicare—and it can be months before anyone knows it.

This can be a real burden for patient, clinician and provider alike. It can take months to sort out--with avoidable expenses occurred all round.

Why is this especially important just now?

States under financial pressures are cutting prescription support programs  for their “dual eligibles,” that is patients covered by both medicare and medicaid.

The result—higher medication co-pays for beneficiaries and a temptation to shop around for a “better deal.”

And an opportunity for scammers to encourage them to do so.

That’s why you should cultivate relationships with your local insurance agent network.  Strongly recommend to each of your patients that they treat their agent as the single resource for their coverage questions--making no changes without consulting with them first.

An extra minute of your time.

No cost to you.

High value to the patient.

Winners all round.

Do it.


High-Value Insight


 A Care and Cost Winner for COPD


My dad died 25 years ago from COPD.


They didn’t have this data  back then. I wish they did.


There have been few studies as compelling as those that demonstrate improved mortality and morbidity in COPD patients using a combo of LABA/ICS/anti-cholinergic inhalers.  I’ve seen the results myself.  Over time, the compliant patient is ill less often, their illnesses are less severe and they’re in the hospital very rarely.


Yet these meds remain very costly, with high co-pays and formulary changes creating significant barriers to long term use.


My solution?


I prescribed nebulized forms of these medications and urged patient to buy a portable hand-held nebulizer out of pocket that they can use on the go. It doesn’t take many monthly inhaler co-pays to off set the cost of a hand-held.


Because of coverage differences, the co-pays on nebulizer meds are significantly lower and the formularies stable.


Compliance with long term triple therapy is a critical component of sustainably caring for your COPD patient.

Get every one of your patient’s to buy in.


I wish my dad had had the chance.

Q&A with Dr. Tom

The status of being a smoker caries no additional capitation, yet the condition is clearly associated with dramatically increased costs.  Any way to capture it?


Simple Chronic bronchitis J41.0


Document that the patient has had a chronic cough most mornings for the past two months


Tie it to their smoking.


Counsel smoking cessation.


Once the data works its way through the system, you’ve just increased your monthly capitation by 30%.

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