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

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.

2. 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. 

3. 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. 

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