From Dr. Tom's Desk

Last week’s newsletter generated an enormous backlash, but after re-reading the judge’s opinion I stand by my analysis that her recent order vacating CMS’ 2014 Overpayment Rule opens the door to a risk-coding free-for-all.
 
As long as you don’t commit fraud, your chances of experiencing any significant claw back in your risk-coding is essentially nil.
 
I recommended that you be aggressive in your coding; don’t commit fraud but feel free to go right up to the line as far as what’s ethical.  Above all, don’t be intimidated or anxious about the process.  The judge outlined in her decision what it’s going to take to create another overpayment rule that would be enforceable.  In her footnotes she even suggests a compliant rule will be difficult to create if CMS insists on retaining the risk-coding system---which is the at the heart of Medicare Advantage.
 
Now is your time to grab a share of the revenue coming out of the Medicare Advantage so you can insulate yourself against the future payment cuts that simply must come. No one else is talking about this let alone publishing this analysis on the internet, but I guarantee that they have all come to the same conclusion.  The insurers, the large organizations---it’s open season on risk-coding---and most don’t see a need to partner with their providers.
 
With or without their provider’s help, they’re going to grab the gold ring.
 
Me?  I started as a little guy, a simple family doctor who used an innovative contract to climb to the top at a time when the current tailwinds were actually directed against my success.  I’m only about helping other doctors and the organizations willing to partner with them do the same, so they can serve their patients well.
 
That’s why here is the only place you’ll read this perspective. 
 
Unless you’re willing to pay the big consulting bucks---there’s no one else looking out for you.

You Should Know

 
Giving Medicare Advantage patients more face-to-face time with their physicians dropped the patient’s healthcare expenses by more than a quarter.
 
That’s the results of a study from the American Journal of Managed Care looking at a pilot “high-touch” primary care payment model.
 
The cost savings are not due to more time with their case managers, their nurses, or their care coordinators.
 
Only their clinicians.
 
That’s no surprise to my clients and the readers of my content, but it’s nice to be confirmed by good research.
 
What was the reason behind the findings?  The authors posit three:
 
“The study gave three possible reasons for the results. More frequent communication between patients and their providers may help promote improved adherence to medication and can also allow physicians to optimize medications as needed. Another possibility is that the frequency of visits may allow for more timely diagnosis of ambulatory care–sensitive conditions, thus allowing patients to avoid the hospital. A third reason is that patients in the high-touch care model may be more likely to receive other preventive care, such as vaccination or cancer screening.”
 
All wrong.
 
I can see the board room discussions of low performing organizations now . . .
 
Let the confusion between correlation and causation commence:
 
“All we have to do is encourage (or coerce) our docs to spend more time with their patients and we’re on easy street.”
 
“Let’s start measuring face-to-face time in the clinic, perhaps paying the docs a bonus for extra time in the exam room.  Or even better, how about a penalty for not spending enough time.  We’ll either generate more revenue to decrease our labor costs---it’ll be a win-win.”
 
Not one in a hundred organizations will understand the reasons behind these findings---findings that I have confirmed repeatedly since 1996---not only in my personal practice but with every single client I’ve work with.
 
With a properly constructed compensation formula, physicians will spend more time with their patients.  More time translates into stronger relationships, more effective curation of medical interventions and a mutually agreeable stewardship of financial resources.
 
Medicare Advantage permits the construction of such a compensation formula.
 
All you have to do is educate your clinicians in how your contracts work and mentor them to success.
 
Now that’s a win-win.

 

Tip From Tom

“An effective hospice partner is a key to your Medicare Advantage success. In today’s competitive hospice market, it’s much easier to find end-of-life providers willing to go the extra mile in exchange for a dedicated referral source.  Cultivating a great relationship with a high-performing hospice will pay off big time---for both you and your patients.”
 
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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