From Tom's Desk

Predicting the Future

Your faithful author has had a jaw dropping week.

He’s been evaluating the Medicare Advantage programs of various systems and clinicians.

As they awaken to the horror that is MACRA/MIPS, they're shifting their efforts to Medicare Advantage, essentially the last bastion of sustainability in the third-party-payer world.

They're putting enormous investments in time, money, and opportunity to upgrade care systems so they can jump on the Medicare Advantage bandwagon and grab some premium while the low hanging fruit can be had.

Many are betting their future.

Are these bets well-placed?  What are the risks of being behind the curve? Are these they being played by their vendors and consultants as the greater fool?


Right now Medicare Advantage seems like the only bet in town.  The funding is fat and the dollars are falling from the sky.

Don’t count on that continuing.

If your investments are based on the premise of those huge cashflows, you're taking an outsized risk.

Continuing the current level of funding will take some combination of increased co-pays, money printing, tax increases, and means-testing of premiums.

Even with that, current dollars will continued to be shifted to higher risk populations--patients who are going to take a lot more effort to generate the margins you're currently used to.

Investing resources like it's no tomorrow based on the premise of current funding patterns is simply bad business. 



Build a sustainable, anti-fragile system—based on reliable coding, bottom-up cost control by shared-risk primes and engendering innovation in care delivery.

One that can thrive in any funding environment.

Don't predict the future, create it.



You Should Know...

Getting ahead of the Curve

A recent Government Accounting Office (GAO) report found data suggesting that in 20% of MA plans with excessive dis-enrollment, such dis-enrollment occurs due to dissatisfaction with access to desired care.

These are the reports that drive program design—and the report explicitly states that " CMS does not use available data to examine. . . dis-enrollment by health status as part of its ongoing oversight . . . CMS may fail to identify problems in MA contract performance, which poses a risk as contracts are prohibited from limiting coverage based on health status.”

Simply put, the GAO is concerned that panel narrowing, a common cost control approach used by many under-performing or poorly designed insurers, may--either incidentally or by design-- be encouraging sick patients to seek care by leaving the Medicare Advantage program.

Be aware. Based on this report, regulatory changes are certainly coming.

Network narrowing is going to become more difficult.

Not that that's a bad thing.  As a form of cost control it well and truly sucks.

Start enlarging your provider pool so it generates value--that way your beneficiaries won't opt out.

Instead of using price as a criteria, ask your providers who generates the most value.

Your primes are the ones driving any loss of ill beneficiaries from your plans.  Engage them in the process.

Create systems that engender a true partnership among yourself, your agents and your providers.

Better start doing it now, because soon, you're going to have no choice.

If you don't, I guarantee it's going to cost you money.

High-Value Insight


In Which I Cost Myself Hundreds of Thousands of Dollars

Analyze your data.

Find your high performing primes. 

Get in their office. 

Follow them around. 

Tear apart their workflows. 

Find another prime interested in replicating it.

Pay the prime to mentor.


Apply. Rinse. Repeat.


A simple insight.

Yet rarely done.

I have no idea why organizations pay me hundreds of thousands of dollars to do something they can easily do themselves.

Q&A with Dr. Tom

I’ve used your house call recommendation to good effect.  But now I’m inundated with my MA patients calling me to perform house calls.  How to I get the genie back in the bottle without hurting my reputation?


Blame the government.


According to Medicare regulations, to be eligible for a house call the beneficiary must be unable to propel themselves across their threshold or assert that doing so would cause pain, medical difficulties or hardship.


If you find yourself the position defending your house call policy, fall back on these regs—and if the patient grouses, give them the number to your local congressman.  They employ folks who are trained to take complaints.

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