From Tom's Desk

Urgent Care

What’s the role of urgent care centers in a shared-risk, value-based world?
For a look, check out the small number of patients and clinicians living in that world right now, such as concierge and direct patient care (DPC) practices.
They don’t use urgent cares at all.
Their patients are paying good money for personal access to their docs, access at need, outside the anti-innovation restrictions imposed by regulators.
They use the emergency room for emergencies---they contact their clinicians for everything else.
Why should they pay for medical care twice?
That’s how the world is going to work under global patient spending caps and that’s how you’ll identify good healthcare systems.
The good systems won’t have allied urgent cares. The systems with over-worked and disengaged primes will.
Today’s world still has enough fee-for-service care to justify urgent care investments, but recognize that those days are numbered.
Concentrate on developing your own primary care network and leave the urgent care centers to the under-performers.


You Should Know...

Late to the Party?

The gold rush has really begun in earnest.  


Bloomberg and Forbes both recently documented the explosion of existing Medicare Advantage Organizations (MCOs) ramping up recruitment efforts as well as new players entering the field.


With commercial product margins capped and an enormous amount of venture capital money sloshing around looking for a return, Medicare Advantage is the one bright spot in an otherwise rotting industry.


We’ve been documenting the trend here for a while, but only as the most recent proposal period has matured has the true scope of the expansion become apparent.


UHC predicts as many as 50% of seniors will sign up be enrolled in Medicare Advantage.


Capital and labor intensive, with a 3-5 year lead time to profitability, these MAO initiatives represent a big bet—-with odds increasingly stacked against success.


Regulatory push-back, the increasing costs and complexity of an aging population and the exponentiating technology requirements are only a few reasons to be cautious.


An unmotivated, disengaged workforce is another.


I’m going to save you hundreds of millions of dollars—-right now.


What worked in the past with Medicare Advantage will not work in the future.


If you try to start or expand a system with the same premium stripping tactics that are currently being used, you’re going to lose your shirt.


In five years—-after spending Lord knows how much money—-almost all these MAOs will be consolidating and deemphasizing their Medicare Advantage lines of service.


Except the ones who actually control their costs by innovating care delivery now.


They’ll have seized the opportunity of a lifetime.


And they'll have the best cared-for patients as well.

High-Value Insight

Pulmonary Hypertension
If your patient undergoes an echocardiogram or a cardiac catheterization, systematically check the documentation regarding pulmonary artery pressure (PAP) measurement.
Pulmonary hypertension (ICD-10 I27.2x), is defined as a tricuspid valve regurgitation velocity of >3.4 m/sec and a systolic PAP > 40 mm Hg on echo or a directly measured mean PAP of >24 on cath.
The measurements are always recorded but are often overlooked by clinicians.
The condition has significant clinical implications for your patient—and can increase your capitation by as much as a third.
So, make it a point to review these results as they come across your desk. If you ordered the test yourself, you should be able to document and submit the code through an addendum to the visit when the test was requested. If not, bring your patient in, address the condition during the visit and submit it at that time.

It’s a great way to catch and bank additional revenue--before you need it.

Q&A with Dr. Tom

What’s the smile test and how should I use it?
As that rare clinician who understands risk coding, it’s possible for you to jack up your RAF score by scrambling for every esoteric risk-code you can find.
Avoid the temptation.
All clinician have experience “buffing” the chart—emphasizing certain aspects of documentation to attain a specific regulatory result.
There were always opportunities to capture the odd risk code just to capture revenue.  Individually, any would pass muster.  Collectively, they would have stood out—in a bad way.
How did I, the Medicare Advantage Master, keep myself out of trouble?
The smile test.
While doing my charts, I would imagine myself defending my documentation and code submission to a peer—someone I knew and respected.
If I couldn’t do it without smiling, I didn’t do it.
I addressed, documented and submitted—all using the smile test.
And I found I slept much better at night.
And was still a tremendous success.
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