From Tom's Desk

When You're Asked to Cut Your Care Management Costs

No one wants to be a chainsaw, most want to be a gardener.

Many organizations are responding to the economic slowdown by cutting their Medicare Advantage "Care Management" staff.

The challenge is, they’re mostly doing it in an indiscriminate manner, indifferent to the net value that results.

The objective financial case for care management services is hard to quantify. And, as significant cost centers with hard-to-prove benefits, they're a natural cost-cutting target when resources become constrained.

Most organizations will simply reduce their workforce and dump the caseload on the professionals that remain---a recipe for mediocrity.

Here’s how you can reduce your costs while at the same time creating value. Reframe the challenges of cost-reduction as an opportunity to re-focus your care management efforts.

If you risk-share with your primes, ask your care managers which primes actually collaborate with them effectively. Then partner a single care manager with one or more of the primes that “gets it.” Let them both work together to figure out which patients will generate the most return on the case manager's time.

What about the rest of the docs and their patients?  Keep one or two care managers around as "free agents," targeted at specific cases where they'll do the most good, but mostly let these low-performing docs watch their peers and learn.

When they get on board with care-management, they can earn the privilege of their own dedicated care manager as well---and you can make the financial case for it to your boss.

 Be careful not to overwork your care management staff by spreading them too thin. Remember the value here is the relationship they create with the patients and the primes.  You can only scale that so much before rapidly depleting overall value. Accept that there are limits to what and how much your staff can do.

It’s so difficult to measure care managers on productivity, instead measure them by how satisfied their partnered prime is with their efforts. That measure cuts to the heart of the value care managers generate.

However, if you’re not risk-sharing with your primes, then controlling your care management cost is easy---cut away until you reach your goal.

Keep enough of the service going to maintain the optics and then spend your efforts on other, more profitable pursuits.

In that case, your care managers are probably not making an impact anyway---so you have little to lose.


You Should Know...

Should You Buy Code-Harvesting Software from that Third-Party Vendor?

CMS is estimating that the portion of possible capitation captured for Medicare Advantage patients is declining. Some studies estimate the average percentage to be as low as 5% of what is possible---most of it is due to missing risk codes.

Seems hard to believe, but it actually reflects how few patients on your Medicare Advantage panels actually come in to see the doctor each year.

As the economy slows down and patients have less money for co-pays, you can be sure the percentage of folks coming in to see you each year will drop even further.

Many third-party vendors are taking advantage of these studies to market their EHR coding add-ons to healthcare and Medicare Advantage organizations.  They purport to help your primes be more efficient in code collection.

Tread lightly before you buy.

Unless your clinicians are motivated in some way (say by risk-sharing), these new tools may please your boss as a “solution,” but they won’t significantly increase your revenue---they may even be a net negative.

And you might be on the hook for an expensive purchase that didn't generate any value.

Your clinicians are at the end of their rope as far as time and data entry is concerned. Unless you change the structure of the system, another add-on is not going to save the day.

So, when your boss or your board asks you about such things, look smart, stay skeptical and tell him the organization should work on incentives, culture and mentorship first----after that, the case for the right code collection product could be strong.

Absent that, the right answer is probably no.


Tips From Tom

Lobar Pneumonia

Have a lobar pneumonia on CxR but no organism on sputum culture?

J181, Lobar pneumonia, organism unspecified can be the code for you.

Depending on the situation, it can increase your monthly capitation by up to 30%---all for checking a chest x-ray when appropriate and submitting an addendum with the code as you can.

You can give yourself a 30% raise on that patient.

Not bad work if you can get it.

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