From Dr. Tom's Desk

“Carve Ins” are the latest threat to your Medicare Advantage performance.  Do you know what services are “carved in” to your contract?  Which are “carved out?”
Since the costs are coming your of your pocket, you had better know.
“Carve Ins” refer to those CMS-mandated services which come out of your pool.
“Carve outs” refer to those CMS-mandated services which do not.
In our contract, hospice was a carve out. Once a patient signed up with hospice they dropped off our panel and we were paid a flat $50 a month fee to manage their hon-hospice care.
It was a great deal. The patient, the doctor, the hospice---all our interests are aligned.
Today, however, more and more contracts are discarding carve-outs for carve-ins. Usually because the Medicare Advantage Organizations (MAOs) have a business interest in those services.
Take hospice. An increasing number are in private hands. They’re putting their business acumen to work to extract the highest possible payment per patient per day.
But if their contract carves those services into your pool, those payments are not being extracted from CMS or the Medicare trust fund. They are being extracted from you.
Often times, contracts are stealthily changed from carve out to carve in with essentially no notice to the organization.  You may be thinking that your hospice or your home health is being paid for outside your contract only to find that their status changes a while ago.
The simplest way to find out is to ask your Medicare Advantage Organization for a list of carve outs.  If they include what you thought, review your care processes to make sure you’re taking advantage of them.
If they do not, make sure your clinicians can use the most cost-effective vendors for those services.
So that they don’t take advantage of you.

You Should Know

More money coming out of your pocket if you’re sharing risk with MAOs.
There was a study a while back featured in the Health Affairs Blog that showed nutritionally “at-risk” patients generated lower short-term costs when given prepared meals.
That is but one of the examples that CMS is using to justify the expansion of Medicare Advantage benefits to include non-medical services.  Medicare does not cover “meals-on-wheels” programs, but starting in 2020, Medicare Advantage just might.
  1. This is yet another example of my previously referred to assessment that there is a concerted effort to move chronically ill patients onto Medicare Advantage at the expense of Medicare.  Yes, once entrenched stake holders such as Kathleen Sebelius and Robert Kocher joint the boards of Medicare Advantage Organizations last year the writing was on the wall---and I called it.
  1. The expansion of these services have not yet come with a commensurate increase in you pool payments, and I don’t expect “nutritional support” will look much different. 
  1. The argument will be made that nutritional support will be funded by decreased costs---that argument will be spurious. Nutritional support may or may not be associated with decreased costs (one study does not the truth find) but even if it does, it won’t prevent long term costs---for all we know, it might make them worse.  And if you’re sharing risk, you’re in it for the long haul now. It’s the long term that matters to you. 
Your tactic is to recognize that government mandates are chip-chip-chipping away at your potential performance. Make sure your docs have skin in the game, are properly taught how to work their contracts and are not overloaded with too many patients.
Don’t let the fat times fool you.  As CMS continues to sip more and more from your milkshake, you’ll need the best systems you can create.

Tip From Tom

If present, phantom limb with pain (G54.6) or without pain (G54.7) is a great way to capture risk in patients who have amputations above the waist as the amputations themselves are not risk diagnoses.
Can telemedicine fill the gap when Samantha loses her doctor?  She learns more than she bargains for trying to keep her family safe. Share her journey.

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