By Roy Edroso, Decision Health, Part B News, Oct. 18, 2017
As more patients choose Medicare Advantage plans, examine your practice to see whether it’s time to start or expand your contracts.
On Sept. 29, CMS bragged in a press release that in 2018, “the average monthly premium for a Medicare Advantage plan will decrease” — a 6% drop from $31.91 to $30.00 — while “enrollment in Medicare Advantage is projected to reach a new all-time high” of 20.4 million beneficiaries — a nine-point lift in one year.
That is remarkable, even as Medicare Advantage growth has been robust for years (PBN 5/23/17). This latest growth spurt may have practices that haven’t engaged MA plans before interested in pursuing those contracts.
New patient opportunities with MA
On the plus side, adding MA plans can refresh your practice with a new patient population. And, given the growth numbers, you may also be keeping Medicare patients whom you might otherwise have lost to private or other MA providers.
“Doctors are realizing patients who’ve been in their care for years are looking to enter an insurance plan that offers advantages over traditional Medicare — deductibles and coinsurance payments are reduced and additional benefits are offered that are not offered in Medicare, such as vision, dental, transportation, hearing aids and gym memberships,” says Donald Rebhur, M.D., co-chair of the Quality and Performance Committee for the California Association of Physician Groups (CAPG) and board member with the Integrated Healthcare Association (IHA). MA plans cannot provide fewer services than Medicare but often provide more.
Also, while it has been a knock on MA plans for years that they pay less than traditional Medicare, CMS has been pushing up the rates, and some payers have in turn gotten more generous with their providers. A paper from the University of Southern California published by JAMA Internal Medicine on July 10 said that now “physician reimbursement rates in Medicare Advantage are very similar to traditional Medicare.”
And with its risk profiling and care and payment models, Medicare Advantage can serve as a gateway to the value-based care that American health care is inevitably moving toward, says Debbie Zimmerman, M.D., chief medical officer of Lumeris and Essence Healthcare in St. Louis. “MACRA is heavily influencing physicians, via traditional Medicare, to move to value-based care, and this should further their consideration of MA,” she says. “In our opinion, Medicare Advantage is the best model to support the type of investments and changes in behavior needed.”
Risks with MA plans
On the other hand the plans make some administrative demands on practices. Because CMS’ payment to MA plans is partly based on risk profiles, practices are obliged to do risk-adjustment coding, and some practices complain that the audits those payers do to make sure that coding is accurate can be burdensome (PBN 5/8/17). It’s not likely to get less burdensome, either, as whistleblower suits are starting to hit Medicare Advantage payers (PBN 4/10/17). Also, unlike traditional Medicare, MA plans can in some cases require pre-authorization for services, which will add to your administrative hassles (PBN 10/10/16).
5 tips when engaging MA plans
- Go big or go home. Make sure you have enough patient capacity to make an MA plan worth your while, says Zimmerman. “First, you need enough patients — that is, a sufficient panel size — to trigger desired behavior changes in the doctors; with only a few patients, it’s not enough to change the way they practice,” says Zimmerman. “Second, you need to have enough patients from a risk standpoint… [so] one outlier patient hopefully won’t throw you off target if you have others to mitigate.”
- Have your head on straight. Is the model right for you and vice versa? “Practices need strong clinical and financial leadership,” says Zimmerman. “The physician organizations need several key components: the right culture and leadership, the right incentives and compensation model, the right information, the right care delivery model and the willingness to invest in the right resources. The physician organizations also need to be open to and embrace change.”
- Check outside costs. Make sure you get some idea of what services will cost your patients on these plans outside your office, especially if you expect your population to need them a lot. For example, “skilled nursing facilitycosts may be different to patients in a Medicare Advantage plan as opposed to the basic Medicare plan,” says Omar Baker, M.D., co-president, chief quality and safety officer and director of performance improvement of Riverside Medical Group in Secaucus, N.J. They also may have different charges for service windows, such as the first 20 days, and other features that may be important to your patients.
- Bargain hard. If you decide to shop payers, be tough with the negotiations, says Brian Donovan, vice president of business development for SE Healthcare Quality Consulting in Charleston, S.C. “[Value-based] programs can make the allure of participating in a new product or network more enticing, but you have to closely pay attention to the key business and financial terms of the deal,” he says. So be aggressive about getting clear numbers, says Donovan — not only in a fee schedule, but also for care coordination per-member, per-month fees; quality benchmarks; and any other payments they might offer for specific care targets.
- Go for top-rated plans. Not only CMS but also independent groups like IHA provide star ratings for plans that are seen by patients and care partners. “When you decide to see patients insured under Medicare Advantage, do your homework … you’re putting your patients’ care and personal reputation on the line,” says Rebhur. “It’s better to be associated with a plan that has achieved high scores by Medicare and has demonstrated a higher quality of care and patient satisfaction.” — Roy Edroso (firstname.lastname@example.org)
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