From Tom's Desk

What Medicare Advantage Can Learn From Direct Patient Care


There is a limit to how many patients a single clinician can effectively care for under a shared-risk system.because it’s the relationship between the prime and the patient that generates the value.


Together, they decide what care is appropriate, desired and needed—-and the clinician (if incentives are aligned through risk-sharing) makes that care happen as efficiently as possible.


But that type of relationship takes time. Time to develop and time to administer. And time is finite; time doesn’t scale.


No amount of technology will speed or deepen that connection—-and anyone who tells you otherwise either works for you or is trying to sell you something.


As a clinician’s skill and confidence grows, the number of patients they can effectively care for increases—-to a point.


After that point, even the most skilled clinician will suffer a decline in efficiency, effectiveness and satisfaction.


It's tempting to scale by having primes simply load up on more patients. It’s tempting too for primes to try to make more money by loading up on more patients.


But it eventually that number grows too large and becomes self-defeating.


What is that number?


Look at the practices of clinicians who perform direct patient care.


If their practices grow too large, some patients will leave, feeling they aren’t getting their money’s worth.

They have a functional cap on the number of patients---a "sweet spot" of around 500 is the norm.


That sort of direct price-signaling is absent in third party payment systems like Medicare Advantage, but you can still see it in your financial results. Pay close attention and limit the panel size you expect from your Medicare Advantage providers.


If your product is growing, get more clinicians. Educate your current clinicians that they have a “sweet spot” in the number of patients they can care for. Let them learn it the hard way if they must. That way you can bring on and mentor new clinicians without triggering a fear of competition.


But don’t try to grow by simply slapping on more patients on an already overloaded edifice—-that’s the one sure way to underperform.

You Should Know...

Hard Data on Satisfaction and Retention

The second annual  J.D. Power(™) Medicare Advantage survey is out and the findings are no surprise—-and they just might provide you the data you need to help make the needed changes in your organization.


The key takeaway is that satisfied beneficiaries are much more likely to stay loyal and advocate for their plans---no surprise there.


But how to you satisfy them?  According to the survey, the better they understand their benefits and the more connected they are with their personal clinician, the more satisfied they are.


The greatest barriers to satisfaction? Rising cost-shifting to patients and poor troubleshooting and advocacy of patient concerns by the insurer through their help line.


Addressing these barriers? A close relationship with a dedicated prime, whose properly aligned incentives encourage engagement, will reduce patient’s costs, improve patient understanding of benefits and address their concerns before they ever have to reach for the variable quality of the dreaded insurer’s helpline.

The data is there---now act on it.

High-Value Insight

Medicare Advantage Benefits Outside the United States

Traditional Medicare will not pay for beneficiaries' care costs if incurred outside the United States or its territories.


Medicare Advantage will.


That piece of information alone is often all beneficiaries need to make a choice.


Make sure they know it.

Q&A with Dr. Tom


During my training about risk coding, I learned something about some codes cancelling out others and some that work together to generate even higher capitation rates.

I’m so confused. What do I really need to know about this stuff?


Not much.


Everything you need to know is in the highly acclaimed “Success Codes” series featured every Monday in Dr. Tom’s Blog—-check out the great graphics from Mrs. Dr. Tom.


In summary


  1. No ICD-10 codes can be submitted without a physician's approval.


  1. Many common chronic illness are associated with increased capitation, you should know them—-they're usually caught by some physician along the way. Capturing them is necessary for exceptional performance, but not sufficient


  1. There are a number of uncommon yet still seen conditions that are also associated with increased capitation—-you should know them. They are usually only captured by a prime with a close, ongoing relationship with their patient. Capturing them is essential for exceptional performance.


As for what cancels out what or which codes works with which code to increase your capitation—-don’t worry about it.


Give your patient what you both agree upon is the most beneficial care as efficiently as possible.


Keep in mind your Success Codes while documenting your work.


And you’ll do well.


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