From Tom's Desk

For Medicare Advantage Success, Work Your Contract As It Was Originally Intended

Social media networks were created to connect people. It was only after their growth exploded that the potential for targeted advertising was realized.

As advertising budgets tighten, large corporations are now suspending their targeted social media advertising buys.

And they're finding their net revenues are going up after this cutback.

Social media advertising isn't adding value---at least not for them.

Medicare Advantage was conceived as a system to control costs by putting clinician's own skin in the game.

It was very effective.

It's since morphed into a data collection play. That too is very profitable---for the insurers.

For the health systems and clinicians expending so much capital on "care management" and "medical homes," not so much.

Medicare Advantage margins are soon going to tighten.  Whether through competitive bidding, increased compliance enforcement or more modifications to the RAF system---it's going to happen.

The number of Medicare Advantage Organizations will diminish and they'll make up some of their missing margin by paying you less.

Keep this in mind as you’re looking at your internal investment plans.

Because of the long revenue cycle in Medicare Advantage, internal investments tend to have long lead times. The investments you make today will be in place when your Medicare Advantage margins tighten in earnest.

It those investments improve efficiency without adding ongoing overhead, you should consider them.

If they do anything else, just bank the resources.

You're going to need them.


You Should Know...

CMS 202 Proposed Rule Continued. . .

Here are some other pearls from part 2 of CMS’ 2020 rule:
  1. The “over-coding” adjustment for risk codes is 5.9%, as low as it can go by statute and not a significant change from last year. Whatever risk-score you achieve from collecting diagnostic data will be adjusted downward by 5.9% before it is plugged in the RAF formula. 
This is good news in as far as the adjustment is as low as it can go, and it may be an indication that the industry is being effective in targeting this single, most important modifier with their lobbying efforts. But don’t get used to it, It's been held down so long that when it does go higher it may just overshoot---and the negative impact on your net performance will be significant.
  1. CMS is going to remove two measures from its STAR ratings for Medicare Advantage:
    1. Adult BMI Measured (BMI itself will still be a risk code).
    2. Blood pressure control (temporary, so as to realign with the new blood pressure control recommendation).

STAR ratings continue to evolve, underscoring the importance of not investing too much in the infrastructure to meet any single metric. Get your patients seen once a year and let your insurance partner do the heavy lifting with the STAR metrics.  That's the recipe for a low-overhead, high-net performing plan.
  1. CMS is moving forward in its efforts to include certain opioid use metrics in its STAR ratings including prescribing rates of high-dose opioids, co-prescribing of opioids and benzodiazepines and rates of patients receiving opioids prescribed from more than one provider.
None of these measures will have a real-world impact on opioid overuse but they will succeed in driving pain patients to marijuana or even underground.  Your best tactic here is to reduce the administrative burden on your providers by letting them know ahead of time what hassles prescribing opioids for their patients will involve.

And teach them the cannabis codes associated with increased risk-scores---they're going to be using them a lot more often.


Tips From Tom

Giving patients something of value in exchange for completing a qualified Medicare Advantage encounter is flatly illegal.
I shouldn’t have to state the obvious but, based on some recent enforcement actions upon which I’ve been consulted, sadly it needs to be said.
Paying people to enroll in a Medicare Advantage plan or even to come in for a visit is an absolutely certain path to a fraud conviction and exclusion from Federal healthcare programs. There's not a lot of grey area there.

Don't do it and don't be a party to it.

The license you preserve might be your own.
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