From Tom's Desk

Tomorrow's Newspaper
2019 Medicare Advantage Events That Will Absolutely Come True.

Here are five items that will absolutely occur in 2019. I've even included metrics with most of them so we can check back in wonder at their prescience come December.

5.  CMS will continue to adjust risk score calculations away from “aged-in” seniors and nursing home patients and towards “dual-eligibles,”---look for a shift of at least 10% in five of the most common risk-codes. 

There are few additional financial resources which can be shifted---so much has already been done.  Look for this to be the last year of this hidden transition.  

Bonus prediction:  Marketing to the dual-eligble population is going to be much more intense---remember, they can be enrolled year-round, so look for the ramp-up in the spring once the draft 2019 rule letter comes out in April

4. More than the current 3% of Medicare Advantage Organizations (MAOs) will announce they will be offering home care services in 2020---but not many more, certainly less than 10%. 

This was CMS’s first real foray into (partially) funding a new benefit by kicking up the overall capitation rate. Good idea, but so far it’s really flopped. No surprise, especially given the current “premium grab” strategy, but MAOs obviously believe the small extra cap is better spent on marketing or political influence than benefits for their customers.

3. Home-visit only Medicare Advantage practices will become a thing. 

I’m flooded with clinicians looking for help in getting one set up.  Now that a beneficiary doesn’t have to be infirm to qualify for a home visit, organizations will hire armies of NPs to perform home visits for those patients resistant to coming into the office.  Remember, the percentage of patients on your panel who are seen yearly is the key metric for all Medicare Advantage success. 

2. Analysis of the most recent open enrollment numbers will demonstrate more than 37% of all eligible beneficiaries are enrolled in a Medicare Advantage program, up from 33% at the same time last year---demonstrating growth that’s significantly higher than expected. 

There’ll be increasing pushback against predatory marketing in the media and a flurry of consumer advocacy books---the best of which will be “Medicare Advantage Confidential---Getting Great Care” by your humble author. Publication date set for the fall.

And now for the most important.

Read carefully---there's lots of money at stake.  Certainly your compensation and possibly your position.

1. Competitive bidding for Medicare Advantage plans.

The country will be divided into "markets." The whole country will be covered, not just select areas. Each of these markets will have a certain number of "slots" available for an MAO to offer a plan. CMS will force MAOs to bid for the opportunity to offer a plan in one of these "slots."  Price, network breadth, additional services will all be part of the consideration process. Offer great service at a low price to both the government and the patient---and you'll win the opportunity to service beneficiaries.

According to CMS, competitive bidding has worked in traditional Medicare with durable medical equipment and ancillary services such as PT---and they believe it'll work for Medicare Advantage. Given my experience with other forms of government contracting, that remains to be seen.

Competitive bidding won’t be announced this year, not even as a pilot. But there will be lots more talk---research publications, major media outlets. I expect the pilots to be announced by CMS in April 2020 for contract year 2021.

But even without the announcement of a formal test program, strategic planners the country over will recognize the challenges and the opportunities competitive bidding will allow.  We'll be exploring the implications in this space next week.

Each one of these five predictions can be front-run to avoid losses and maximize gains.

For example, after sharing the hitherto unpublicized shift of resources to dual-eligibles with one of my clients three years ago, he went all in on that population and has more than doubled his net revenue with a panel of fewer patients.

It cost me money (I charge him a flat pmpm fee), but he did send me to the Florida Keys for a couple of weeks as a thanks.  

You can front run these trends as well. It'll make you look brilliant, your organization healthier and your patients more satisfied---as well as deeply appreciative.



Make it your New Year's resolution to contact me about a challenge you're facing in your Medicare Advantage program.  You’ll get exceptional value from a unique, operational point of view born in the trenches. 

And you won’t even have to send me to the Keys.

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