From Tom's Desk

Puerto Rico's Unique Opportunity

Puerto Rico was essentially destroyed by Hurricane Maria.  Here's a guide to how you can help in the short-term.

The long-term will not be so easy---but the promise for everyone is potentially enormous.

What poor fiscal management did to the economy, Maria did to the island's infrastructure.

It's now a tabula rasa upon which an ambitious, service oriented organization can rewrite the rules.

What I wrote about Puerto Rico six months ago, goes doubly now.  With the current disaster comes the promise of further regulatory relief, financial incentives and the loss of incumbent actors and institutions---making the opportunity that much greater.

The Medicare Advantage program provides the structure and resources to enable the creation of a true value-based care model.  One where extraneous care is avoided and the patient provided only with the care that they and their clinician value.

Expensive and risky?  Yes.  

But imagine the returns on the system you could create---unprecedented returns for patients, clinicians and your organization alike. Returns associated with goodwill that will follow where ever you expand.

It's a tremendous opportunity.

Who will take it?

Reprinted from VBT #9

Both Puerto Rico and the Federal Government have the same problem: decreased access to quality healthcare for the underserved. And both are trying to address this challenge independently. Taken together, this combination of efforts has created a significant opportunity which could generate huge benefits for patients and the organizations who serve them—that is, if someone with vision will take it.


At the same time as the island commonwealth has dramatically decreased personal taxes for physicians to prevent their outmigration, CMS has begun efforts to shift resources into the care of underserved groups through adjustments in how it calculates its capitation rates—-adjustments which should greatly increase the potential revenue of Medicare Advantage plans serving the island. Add to that the fact that the ratio of primary care clinicians to specialists in Puerto Rico is as close to optimal as it comes and you have a recipe for a Medicare Advantage system that could deliver excellent healthcare, create high levels of clinician engagement and generate long term, accelerating revenue growth.


It’s a unique opportunity for the insurer or integrated healthcare delivery organization with the means and the expertise to execute it. By either leveraging existing or creating new Medicare Advantage networks on the island, the right group could take these new conditions and create a national model of service, quality and profitability. 


The only question that remains: who’s going to be the first to try?






Puerto Rico y el Gobierno Federal tienen el mismo problema, acceso disminuido a la atención de salud de calidad para los desatendidos. Y los dos están tratando de abordar este desafío independientemente. En conjunto, esta combinación de esfuerzos ha creado una oportunidad significativa que podría generar grandes beneficios para los pacientes y las organizaciones que los sirven, pero solo si alguien con visión lo tomará.


Al mismo tiempo que la comunidad isleña ha reducido drásticamente los impuestos personales para los médicos para prevenir su emigración, la CMS ha comenzado esfuerzos para transferir recursos al cuidado de grupos desatendidos a través de ajustes en cómo calcula sus tasas de capitación, ajustes que deberían aumentar considerablemente el ingreso potencial de los planes de Medicare Advantage que sirven a la isla. A esto se añade el hecho de que la proporción de médicos de atención primaria a especialistas en Puerto Rico es lo más cercana posible a lo óptimo y tiene una receta para un sistema de Medicare Advantage que podría brindar una atención médica excelente, crear altos niveles de compromiso clínico y generar el crecimiento de los ingresos aceleradando a largo plazo.


Es una oportunidad única para la aseguradora o la organización integrada de prestación de servicios de salud con los medios y la experiencia para ejecutarlo. Al aprovechar o crear nuevas redes de Medicare Advantage en la Isla, el grupo adecuado podría tomar estas nuevas condiciones y crear un modelo nacional de servicio, calidad y rentabilidad.


La única pregunta que queda: ¿quién va a ser el primero en intentarlo?

You Should Know...

Employment Trends in Healthcare 

The most recent study (here, behind a paywall) of consolidation in the healthcare industry demonstrated some historic shifts that you may be able to take advantage of.


The percentage of all physicians working for an integrated system rose in 2016 to close to 50%, with the most rapid increase seen in primary care, whose employment rate has almost doubled in five years.


Makes sense. Primes have less cash flow, tighter margins and are less able to absorb the costs of regulatory compliance.


Though overall the rate of consolidation has slowed in the past year, it’s expected to pick up again as MACRA hits the cashflow of those that are left.


Now, here’s where the opportunity presents itself.


As one might expect, consolidation has increased costs both to insurers and patients with no concomitant improvement in quality. No surprise.


Medicare Advantage Organizations (MAOs) are recognizing this. And they’re giving sweeter contracts, with more gain-sharing, to their smaller providers.  


With a greater opportunity for financial success, the hope is that these smaller systems will resist the tide of market consolidation. They might even do better on a percentage basis than larger systems—-and this recent study supports this conclusion.


If you’re a large system, particularly with indifferent performance, it’s time to reassess your care delivery systems from top to bottom. Make sure your incentives are in place and your innovation mechanisms are tight and sound.


If you’re a medium or small practice, contact your MAO and see what they can do for you to sweeten your contract. If you have a good track record, you just might be surprised what they’re willing to do.

High-Value Insight

Hepatitis C

With the current universal screening recommendations, plenty of people are screening positive for Hepatitis C (ICD-10 B18.2 RAF 0.2) but, unfortunately, don’t follow up for treatment. They’re not feeling bad, the treatment is expensive and, though much better than interferon, is still associated with side effects.


If they do follow-up as recommended, it’s one of the code families you don’t have to worry about. The specialist will have to pick the specific code(s) to get their treatment covered. The most you should do is make sure you check their protein balance so you don’t miss some co-morbid malnutrition.


However, since many patients will ignore your advice when their test turns positive, you must put a system in place to submit the code with an addendum to the screening visit when a positive does occur.


These non-compliant patients will rack up enormous care costs over time. The sooner you begin to bank resources to cover those costs, the more solvent you will be.


Q&A with Dr. Tom


My organization has an embedded “Coumadin clinic” to monitor anti-coagulation. Should I use them for my Medicare Advantage patients?




Sorry, that should actually be…




These stand alone clinics are primarily revenue generators for organizations. In order to generate those dollars, they routinely charge high level visits for each Coumadin “counseling" session, directly draining the resources of your pool.


And because the counseling is protocol-based and usually performed by a nurse, the frequency of visits  are based on a one-size-fits-all approach directed toward liability mitigation rather than efficiency.


There is no unbiased evidence they do a better job than you.



But plenty of evidence they cost way more.

Plus, patients want to feel like they have a "medical home."  My patients far preferred coming to "their" office, getting stuck by "their" nurses and knowing the Coumadin management decisions came from "their" clinicians.

It was one more bonding experience.

It made them feel their personal clinician was looking out for them.

And that generated true value all round.


You can check out the latest guidelines from the literature for VTE and AFIB.


And just say no to Coumadin clinics.

Just say no.

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