From Tom's Desk

So, what have we learned in the six months since we started this publication of weekly value? Plenty.

This week, lets do the big picture as it relates to Medicare Advantage.

The shifts of resources, both legitimate and fraudulent, from Medicare to Medicare Advantage has created the conditions for exponential enrollment growth—growth that’s now being realized.

This open enrollment period should break all records.

That’s good.

But serious, very serious, compliance problems are being exposed—-that’s bad.

The regulatory push-back has already begun. It’ll certainly threaten the profitability of larger organizations—-and result in criminal prosecutions for the smaller.

Your tactics?

A culture of compliance simply must be your first priority—-higher than recruitment, higher than coding, higher than net margins.


Compliance. Compliance. Compliance.

Only then will you keep the whistleblowers at bay.

More trends and tactics next week.

You Should Know...

More Quality Program Cancellations

CMS announced this past week that it's begun the process to effectively alter or cancel altogether three payment programs first instituted last year. The programs centered around post acute care for cardiac catheterization, bundled episodic care and the global total joint replacement program.

These compensation program changes are happening so often, it’s no longer news—just like the third time they delayed ICD-10.

The Total Joint program changes are especially egregious. Announcement of the program last year sent Katrina-like waves through the orthopedic community.

And now?

Never mind.

How much organizational time, how much in consultant fees, what opportunity costs did you and your organization incur in the process of complying with these programs—-only to have them cancelled.

How many truly beneficial systems were put on the back-burner?

As these programs proliferate and your resources are increasingly limited, do you have a strategy so you can be pro-active or are you simply responding to events?


Simply responding is beginning to cost a lot of money---with no real gain.

None of these programs, not even MACRA are inevitable. Focus on your core services and execute them well. Programs that don’t reward you for doing good work are either not going to stick around or won’t pay you enough to justify your opportunity and capital costs.

That’s how you present it to your boss.

And when your organization's net performance exceeds others, that’s how you'll become her champion.

High-Value Insight

As many as one in eight adults are alcoholics. 

How many see you for numbness and tingling in their extremities?  

If you can link those symptoms to their alcohol use and document it appropriately with G62.1 alcoholic neuropathy, you’ll increase your monthly capitation by up to 50%.

But if you do, either order a B-12 and RBC folate and do some alcohol cessation counseling or document why you did not.

That way you can avoid being listed on this page.

Q&A with Dr. Tom

My patients are being managed to death. With all the “care management,” “care coordination” and “managed care champion” programs at all levels—both at my organization and at the level of insurers—they’re getting fragmented, contradictory advice and they're checking out on everybody, even me. At the least, it’s undermining our relationship.

What can I do?

Call those managers and tell them to stop.

But be nice about it. At least at first.

These systems are created to make the insurance company money---and, depending on your compensation formula, you might actually get a share.

If the continual contacts annoy your patients, call up your insurer's provider relations line, ask them to back off, and tell them why.  And maybe you’ll free up some of their time so they can help other patients who clinicians aren’t as engaged as you.

If they keep doing it, call again.  But speak to the supervisor this time. Explain that their calls are resulting in more costs—-not less, and possible enrollment loss. Try to be nice again.
 

If it keeps up,  you have a much more serious problem.  Possibly a systemic problem.


Your employer and/or insurer may be executing a plan to supplant their Medicare Advantage primes in favor of a more industrial approach.  An approach where you're a patient's prime in name only and the health system itself wants to be seen as the patient's "doctor".
  

If true, prepare to be marginalized, overworked and have your compensation cut.  You're about to become an interchangeable cog in the factory of corp-med.


Allowing primes to control care-coordination with their patients is an excellent test as to how your sponsors view your role.
 

If you can’t push back within the organization, it may be time to find a better one—-there're plenty out there.
 

Because if you can’t push back with effect on something like this, bad things (compensation cuts, increased documentation demands, loss of local control) are coming your way.
 

I absolutely guarantee it.