From Dr. Tom's Desk


 We’ve recently discussed how next year, CMS is going to allow Medicare Advantage Organizations (MAOs) to offer home care services, with no additional compensation to fund this new, potentially very expensive benefit.
 
What we didn’t discuss is that those non-medical home care services are going to include adult day care.
 
That’s right, dementia patients and others who qualify will be able use adult day care services on your dime.
 
How much is the risk adjustment for the diagnosis of dementia?  Zero
 
Adult day care will just be another expense coming out of your pool.  You’ll be required to pay for this new benefit with absolutely no additional resources. Depending on the costs, it could represent a significant drain on your performance.
 
Your tactic?
 
Well, the expense is not yet great enough to recommend cherry picking younger, healthier patients for your panel---ones that are ill enough to generate revenue but not yet so ill as to require these new benefits.  But if the trend of expanding services without offsetting increases in capitation accelerates, we may get there---as distasteful as it sounds.
 
You see, Medicare Advantage Organizations believe these new benefits will help them recruit new patients, and thus offset their costs.
 
You, as a provider, can only take care of so many patients---so the marketing upside of these new benefits is of no real value to you.
 
All you can do is counter-market these services to your individual patients and try to limit their use best you can.
 
And watch for the trend.
 
If things get too bad, cherry picking patients may be the only defense you have.

You Should Know


If you have a patient who is in both the VA and Medicare Advantage healthcare systems, the best way to determine where they are going to get most of their care is to ask them about their drug copays.
 
According to a recent study in the American Journal of Managed Care, veterans with no co-pays on their medication through the VA are more likely to get all their care through the VA than their Medicare Advantage PCP. 
 
Although medical expenses incurred through the VA are not deducted from your Medicare Advantage pool, neither is the VA’s diagnostic data submitted to CMS for risk code calculations---making these dual enrollees two-edged sword.
 
The worst-case scenario for you is that these patients never come to see you and get risk coded, but then wind up in a hospital outside the VA for a catastrophic event. Those costs will most definitely come out of your monthly capitation, and that capitation won’t reflect the severity of their underlying disease burden---it’ll take you a year to catch-up.
 
So, ask your vets at their first visit how much their VA medication copay is.  If there isn’t one, watch out! 
 
It’ll be well worth it to spend extra time bonding with them and reviewing the importance of at least yearly visits.
 

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