From Tom's Desk


The Mystery of the Questionable Hospice Sale---Solved!!!!

I've written in this space about how United Healthcare sold off it's Optum hospice unit despite the critical role hospice plays in cost control under it's Medicare Advantage products.


I wasn't able to puzzle it out.


Mystery solved.


The unit was sold to a number of private VC groups. I missed it because it wasn't mentioned in any of the SEC filings I routinely review in my never-ending quest to divine strategy.


The VC business case for the acquisition is that data review of the electronic health record will allow the newly private entity to select patients for hospice enrollment while at the same time controlling costs.


Someone has sold those venture capitalists a pig in a poke.


Even with close personal spiritual and confidentialist relationships, the conversion of the terminally ill to hospice is very low. The conversion rate of patients identified remotely through the EHR is going to be much lower still—that is, assuming their algorithms can even accurately predict who’s at the end of life (based on other medical risk-scoring systems, I am HIGHLY skeptical). 


With technology infrastructure expenses, likely payment restrictions and increasing compliance costs, I can’t see data-mining for the terminally-ill as an attractive long term play---even with the mega-trend of an aging population .


Why is this important to your Medicare Advantage plan?


Because venture capitalists are listening to the same pitch when being asked to invest in a Medicare Advantage Organization (MAO).


They're being told that data analysis and extraction strategies will generate the risk-code submissions they'll need to earn reasonable return on their investment.


It might even work---somewhat.


But the return for an MAO structured with an aligned primary care workforce would be much, much higher.

Training primes in risk-code identification and documentation is much more cost efficient than back-office data extraction.  And the "bottom-up" innovation of  ever more efficient care delivery will create a level of cost-control that no "top-down" system can ever approach.


Let me know if you find a venture capitalist willing to listen to that pitch.

'Cause it's a winner.


You Should Know...


New Open Enrollment Period Proposed

An additional longer open enrollment period (OEP) at the beginning of the calendar year is among the proposed changes that CMS is requesting public comment upon.




1. Beginning in 2019, the "new OEP" will be January 1 through March 31 each year.

2. Allows enrollees in an MA plan to make a one-time election to join another MA plan or original Medicare. Part D coverage (MA-PD) can change. 

3. During this time period a beneficiary may make the following changes:
  • a. MA-Only to MA-Only
  • b. MA-Only to MA-PD
  • c. MA-PD to MA-Only
  • d. MA-PD to MA-PD
  • e. MA-Only or MA-PD to Original Medicare without PDP f. MA-Only or MA-PD to Original Medicare with PDP

4. Beneficiaries in original Medicare cannot use the new OEP, regardless of Part D coverage.


5. MA Plan can choose to not accept OEP requests.


The idea is reportedly that the additional time to switch would lead to more beneficiaries changing to higher rated plans. Of course, one of the benefits of being a five-star plan lies in the fact that such plans can enroll patients year-round.


No word yet on what these higher-rated plans think about watering down the benefits of their high STAR rating---and the money it cost them to attain it.


Yet another reason to be circumspect as you chase star dollars---the race never ends and the rewards of winning are ever uncertain.


High-Value Insight


Gallstone iIeus

Gallstone disease is common, expensive and yet carries no additional risk payments---that is unless it's associated with an ileus (ICD-10 K56.3. RAF approximately 0.3).


I can't tell you how many gall bladder surgeries I've paid for by making sure the associated illeus was documented.  The code was almost always missed by both the surgeons and the coders.


Gallstone ileus is almost always present and will cover the cost of the needed surgical care.


Don't miss it.



Q&A with Dr. Tom

When my dual eligible patients get admitted into the nursing home for permanent placement, the administration is quick to change them over from their special needs plan to traditional Medicare with Medicaid.


When challenged about this they cite the financial advantage to the patient with no reference to the medical benefits of the program.


Sometimes they even dis me in front of the patient as being out to make a buck. I'm losing a lot of revenue when these switches happen and it makes nursing home medicine a losing proposition.


How do I handle this?


Carefully and then forcefully.



Take time to educate the nursing home administration regarding the benefits of special needs plans. Explicitly admit the financial benefits to yourself---and emphasize that those benefits keep you able to take care of your nursing home patients---and referring them patients.


Engage with them. Demonstrate that your presence in the nursing home is of significant value to the organization and the nursing staff.


Ask to be present when any discussion about enrollment changes occur.


Give it a little time to build your credibility.


If it keeps happening take a private meeting with the administrator.


Advise them of your concerns, the steps you've taken to address them and the continued concerns.


Tell her in no uncertain terms that if the behavior continues you are not only certain to discourage your patients from using their facilities, but you will be advising your colleagues of their behavior and the threat it poses to to their livelihoods and business models


Put her on notice that you will cease seeing any patients in the facility if it happens again.


Then follow through.


Don't worry about the patient. If they feel strongly enough that they must be in that particular nursing home that they're willing to change doctors, then your bond with them isn't as strong as it needs to be---and certainly not strong enough to provide cost-efficient care at the end-of-life.


Let someone else deal with all the uncompensated care and the increased liability which fee-for-service nursing home care entails.


Better a stable of a small number of collaborative nursing facilities than messing with a whole bunch, who don't respect you.



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