From Tom's Desk

Insurer-Owned Primary Care Practices

There's something new under the sun . . .


Insurer-owned primary care practices.


Without the prejudices of healthcare delivery organizations (HDOs), insurers understand that the true value generation from their Medicare Advantage plans lies in the relationships between the prime and their patient.


They have the resources to leverage that relationship.


And they're  without the baggage of having to support an infrastructure of specialty services and the specialists who provide them.


Insurers see specialty services as the cost centers they actually are and contract with them like any other vendor.


For the traditional “integrated healthcare delivery organizations,” this combination of insight, resources, and execution will be deadly.


Already, United Healthcare is employing over 20,000 primary care clinicians. Their numbers are growing and, by all accounts, the docs are happy.


So if you are an integrated HDO, beware. Your competition isn't unaligned clinicians---you've won that battle.


It's your own insurers.


And given the comparative cost structures and needs, you should be very concerned.




You Should Know...

Value-Based Insurance Design Model Accelerated

The federal government announced late last month that in 2019 it will be expanding the availability of its Value-Based Insurance Design Model (VBIDM) to Medicare Advantage Organizations (MAOs) to 25 states — up from the current 10 in that will be allowed in 2018.  


The model is designed to encourage chronically ill seniors to use "high-value" services by lowering out-of-pocket costs.  The exact definition of "high-value" is left to the imagination but it's implied to mean "services that decrease costs."


However it's defined, the VBIDM model must be outperforming expectations to justify such an accelerated rollout.


The real question is whether your organization should consider bidding for a plan under such a model. 


If your system is well-designed and executed, the barriers preventing your chronically-ill enrollees have already been addressed. The additional compliance headaches of yet another model pilot are definitely not worth any additional increase in your net revenue.


If your system is not well designed, there's nothing in the VBIDM that's going to generate more value than simply improving your existing plan design.


For poorly performing systems, forget the extra overhead---better your own care delivery instead.


High-Value Insight





Its use can be a marker for the presence of Angina (ICD-10 I20.9).


If you see it on a patient's med list, go looking for the indication for its use.  If it's angina, make sure you address it, document it and submit it.


Congratulations, you've just increased your monthly capitation for that patient by up to a third.


Watching for nitroglycerin us is one of the simplest Medicare Advantage "success tactics."

Watch for it---both you and your patient will prosper..


Q&A with Dr. Tom


What do I do about a patient that requests specialty referrals but won't come in for a routine exam?


Take action.


Call the patient yourself and tell them you've received the referral requests but that as part of the insurance coverage they chose, they need to see you first for an evaluation.


Many patients sign up for Medicare Advantage without being completely educated on how it works.  Give them that education. Refer them to my post on how Medicare Advantage works.


And ask them to come in.

Tout the health benefits and cost savings inherent in such an encounter.


If this is the first time this has been a referral problem with this patient, consider signing a referral sight unseen — if the patient agrees to make an appointment.



But if after your explanations and efforts, she still doesn't follow through or repeats the behavior, don't issue any referrals at all.



What you have there is more than likely a "gamer."


Someone who wants the benefits of their Medicare Advantage plan with none of the restrictions, none of the costs.


In essence, she's asking you to pay for at least part of the cost of her medical care.


Don't let the patients on your panel do this to you.


You're much better off without them.


Your insurance company and employers know the score. Any complaints will fall on deaf ears, so don't worry.


Once they realize you won't play along, these patients will try to find some other sucker to support their uneducated (or dishonest) approach to healthcare.


These patients tend not to have a very great circle of influence---and the folks they do have influence over, you don't want.  So any bad word of mouth is not a real concern.


Don't be a patsy for these patients trying to get extra benefits for no extra cost.



If one of your patients tries to turn you into a "referral monkey"--- just say no.

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