From Tom's Desk

Generalizing the Medicare Advantage Experience

Harvard has finally caught up with me.



In a recent editorial in the Harvard Business Review, author John S. Toussaint opines that expanding Medicare Advantage to broader populations is one way to extend health care coverage and limit costs.



Have the clinicians share in the financial risk of delivering healthcare and show them how to do it right.



That's the ticket.



I've been spreading that news for twenty years---it's nice to see my influence spreading to the HBR.



If you look at every major expansion in healthcare---Medicare, Medicaid, the ACA, they all started as ideas published in the Harvard Business Review.



All of them.



So, get your house in order. Create effective anti-fragile systems with tight feedback loops.  Amp up your compliance culture (see below).



Opportunity is coming.  The Medicare Advantage Model is spreading.



Will you be in a position to answer the call?


You Should Know...

Push for MA Claims Data Grows

Every major transparency push in the Medicare and Medicaid program was signaled by an editorial in the Journal of the American Medical Association (JAMA). 



Here comes another.



JAMA last week released an editorial asking for CMS to release of claims data for Medicare Advantage (MA) patients.



Long available for patients in traditional Medicare, MA claims data was scheduled to be released by CMS last year---only to be canceled abruptly due to data quality concerns.



The behind-the-scene worry is that the claims data will reflect massive overcharging by Medicare Advantage Organizations through the over-representation of the disease burden of their beneficiaries.



Such transparency initiatives have always led to increased compliance scrutiny.



This one will as well.



What to do?



Make sure you and your partners are engendering a culture of compliance at your organization, with every risk code vetted and accurate.



You'll sleep well at night during the coming storm.



Others won't.

High-Value Insight

Portal Hypertension


The key to succeeding in Medicare Advantage lies in making sure you catch all the co-morbidities associated with severe illnesses.



That's the only way to book enough revenue to cover the care costs of your patient's severe chronic diseases.



A simple and easy condition to look out for is Portal Hypertension ICD-10 K766.



It's present in so many illnesses, ulcers, alcohol use, varices, cirrhosis---yet it's very rarely diagnosed when those problems are addressed.


If you see a condition where portal hypertension is a concern, check for it.



If it's there and you've addressed it, then code for the condition appropriately



It might increase your monthly capitation by 50%

Watch for it, your patients will thank you.



Q&A with Dr. Tom

I've a number of seriously ill patients on my panel who are into their re-insurance coverage for the year.  I've been working hard to restrict their care but the overall financial performance of my panel continues to be poor.  What am I doing wrong?






Reinsurance coverage for your Medicare Advantage patient panel is one of your most powerful tools to limit your losses.



Use it.



For example, if you have a $100,000 year-to-year re-insurance policy with a no limit 90/10 split, the reinsurer will pay you back for 90% of the money you spent on that patient's healthcare over the course of a year less the first $10,000.



Don't know your re-insurance levels?  Ask your provider relations contact, they'll know




Reinsurance is a mighty tool.  So powerful that I and my partners created our own reinsurance product to amplify the benefit.




If your patient's care costs have hit your cost limit, it's not the time to restrict their care.



It's the time not to worry about it.



Do whatever you have to do to get them better.



And hang how much it costs.



The reinsurer will eventually cover most of it.



Also, don't try to game the system by moving up healthcare costs into December just to get it covered by their reinsurance


Gaming the system is not how you succeed.


Being your patient's physician is.

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