From Tom's Desk

Special Needs Plans (SNPs) can be your ticket to even greater success in your Medicare Advantage Organization. Or even greater risk.

The plans provide targeted benefits to specific beneficiaries, with the extra services tailored to the needs of their specific medical conditions.

CHF. COPD. Diabetes. These are just a few of the illnesses targeted by these benefit packages.

The cost of the extra benefits come out of the capitation payments paid by the government, though those payments are goosed a bit based on the individual program.

In general, SNPs are great for the government—-they tout the innovation and service of the offering.

They’re great for the insurers—-they’re an extra hook for marketing.

For providers? Not so much.  They can be a real pain and take up a lot of your provider's time

The expectations and services built in to them can be more expensive than the extra capitation—-especially if you don’t have the extra revenue written into your compensation agreements.

In general, SNPs based on demographics are a better bet for clinicians. Examples include plans directed at “dual eligible” Medicaid beneficiaries or nursing home patients (they’re the best!). They’re easier to administer, the benefits are more targeted at prevention and patient expectations are generally lower.

Consider that when the insurer asks you to add a SNP to your book of insurance.

Need help evaluating your choices?  I’m just a phone call away.

You Should Know...

As the application deadline for the third year of CMS' Value-Based Insurance Design (VBID) program approaches, it’s gratifying to see how many organizations have taken my advice.

The VBID was created by CMS to give Medicare Advantage Organizations (MAOs) the opportunity to offer targeted benefits and reduced out-of-pocket expenses beyond the SNPs discussed above.

Complicated to create, costly to administer, with limited opportunity to truly innovate, just nine organizations in three states are currently participating—-everyone else has just said no.

The problem? VBIDs ask organizations to innovate without allowing them the flexibility to truly tailor their products to local conditions.

Not participating is the most useful feedback organizations can give to CMS---the message being that the government should allow organizations greater leeway to innovate.

Currently there's stalled legislation that could expand the program, though it’s unclear how much more flexibility MAOs would be given

VBIDs are a good idea. But to truly innovate, CMS has to loosen the reins.

Even if the program is expanded, don't participate until your efforts can actually make a difference.


Innovating within your organization will generate a much greater return.

High-Value Insight

This week’s insight a little different—-but in some ways it’s the highest value tip I’ve ever written.

A relative recently was recently admitted as an inpatient for a kidney stone retained after lithotripsy. Despite the acuity of her symptoms, it took two phone calls to the doctor and two trips to the ER to get her the treatment she needed.

The morning after her admission, feeling much better after a ureteral stent, she ordered Eggs Florentine for breakfast. Feeling the edge of her first appetite in several days, she uncovered the tray to reveal one poached egg on a piece of toast, and underneath the egg—-one single leaf of spinach.

Having anticipated the spinach, she ordered a replacement meal and there it was again—-a single leaf of spinach.

No special diet. No special requirements. The “Eggs Florentine”, she was told, came with one leaf of spinach.

For a punchier menu, the someone decided to add the word "Florentine" to the  "Eggs"---but that was only worth the cost of one spinach leaf, no more.

In the meantime, the total avoidable care costs incurred by a single episode of inefficient care ran into the tens of thousands.


That's a lot of spinach.

Q&A with Dr. Tom

One of my favorite specialists is not accepting my largest Medicare Advantage plan next year? What can I do?

Something.

Do Something.

Too many clinicians sit passively by and let the insurers dictate specialty panel composition.

Medicare Advantage, more than any other insurance program, is a collaboration between the prime and the insurer.

If you have a favored specialist that’s dropping out, whether by choice of by force, call them and ask why.

Then call your insurer’s provider relations line and begin the discussion.

Make the case why it's everyone’s best interest to keep that specialist in the game. Have some numbers to back it up; patient satisfaction, utilization etc. But make case.

Making the case itself is more than half the battle.

Just by demonstrating passion and engagement you’ll impress your insurer—-and that alone might be enough.

Frequent causes of "specialist-drop-out" are reimbursement rate reduction and network narrowing.

Both of these are done by insurers using a broad brush.

There’s plenty of wiggle room for an exception—-particularly if it’s presented with engagement and passion.

A waste of time? Hopelessly naive?

Before my experience in Medicare Advantage, I would have agreed with you.

But I have seen the influence borne of passion and engagement with my own eyes.

Just try it.

Go to bat for your favorite specialist.

You will see the influence too.