From Tom's Desk

New Competition Enters the Healthcare Space

The beast has awakened---and it’s coming for your organization.

Amazon, Berkshire Hathaway, and JP Morgan are combining forces, creating a not-for-profit to "revolutionize" healthcare delivery.

Ostensibly, it’s to decrease the societal burden of healthcare spending---though they may just be looking to take a piece of your pie.

Either way, it's not an overstatement to say this partnership is a potentially existential threat to your organization and career.

The resources and expertise in play are going to be difficult to co-opt, let alone outcompete.

Fortunately, you have a weapon which they do not yet possess.

Your clinicians.

If you've responded to the past writings here, if your clinicians have their incentives aligned, are not overworked, and have skin in the game, then you're going to be fine.

That's because you understand the emotional product that is healthcare.


And your clinicians are well placed to innovate the delivery of your product.

If you don’t have these systems in place—well, you're about to find out how Sears feels. And Kodak. And Blockbuster. And Zenith. And.....
 

You Should Know...

Encounter Data Even More Accurate Than Previously Thought

The Office of the Inspector General released its report on claim accuracy using encounter data---and the results may affect your risk codes

As discussed previously in this space, the transition of risk code collection from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS) will decrease overall risk scores for Medicare Advantage Organizations, though perhaps not as much as thought.

The multi-year transition has already begun, though the pace was significantly slowed recently, with only 15% of next year's risk scores being calculated using the EDS.

Now comes news that encounter data is even more accurate and error-free than previously thought, with only 5% of corrected submissions containing at least one error---and those errors only coming from less than 2% of MAOs.

The lesson?

The Encounter Data System blocks the submission of fraudulent data---and this will be used as ammunition in the effort to reverse the current course and push the transition from RAPS to EDS even faster.

And force your risk-scores down sooner.


What can you do?


As painful as it sounds, redouble your efforts at code submission accuracy---not volume, accuracy.


The pain is coming, get it out of the way early.


That way, while others suffer, you can thrive.

We'll keep you informed
 

High-Value Insight

Coding HIV for Success

When coding, treat HIV (B97.35, RAF 1.5!) as you would a cancer.

That is, make sure you capture codes for absolutely every associated co-morbidity and every anti-retroviral side effect.

The weight loss, the fungal infections, the neuropathies.

Everything.

HIV treatment is very expensive. Ongoing management due to poor response and poor compliance even more so.

So do as you do with cancers. Nail down every complication---especially when they're subacute.

You're sure to need those resources later on.

Q&A with Dr. Tom

All my Medicare Advantage patients complain about needing referrals to see a specialist. Either they don't understand why or they are hostile to the idea.  Sometimes their specialists egg on their hostilities.

This is taking up lots of time and costing me some patients. How do I handle this?

Be proactive.

Every new Medicare Advantage patient should be invited in for a "first time" visit.

That's when you explain the mechanics of Medicare Advantage and how they benefit their health and their finances.

The structure, mechanics, and goals of the program---and how they work in your office. Of course, you'll have to understand them yourself.

You must assume your new patient has absolutely no idea what they signed up for.

The process not only sets the tone and expectations for your relationship, it sets in place the first stones in the foundation of trust between you and your patient.

And it's through that trust that true value will be generated.

As for any specialist that gives you grief about needing referrals---fire the bastards and don't look back.


It's the only way they'll learn.