Republican, Democrat or Independent; Provider, Patient or Payor, It
doesn’t matter what side of the line you fall on – we can all agree on one
thing – Healthcare Reform is as necessary as it is Inevitable. We must align
ourselves for the paradigm shift that lies ahead. We can’t continue to repeat
the same actions over and over again with the expectation of different results?
That, by definition, is insanity.
I recently wrote an article, “Mission Critical, Target Missed: $34.1 Billion in Overpayments to MA
Plans in 2012” in which I referenced a recent study that found MA plans
were (on average) overpaid $2,600 per beneficiary last year. If we break that
down month over month we are looking at approximately $200 per month per
enrollee. What did MA plans spend that money on in 2012?
How did their
enrollee’s experience of care compare to their neighbors who elected to stick
with traditional Medicare? And what about the providers who took care of these
patients? How did their experience of providing care to MA members compare to
those patients with traditional Medicare?
It might surprise you that the answer to that question would
fluctuate greatly depending on who you asked, where they lived, what type of
care they needed (or provided) and what plan they were enrolled with (or
contracted with) last year.
According to the Kaiser Foundation, Medicare Advantage
enrollment grew by 10% in 2012, exceeding 13 million enrollees or 27% of the
total Medicare population. Of those 13.1 million, only 26% of all Medicare
Advantage enrollees were covered by plans that were rated as above average or
excellent, and 575,000 enrollees, about 9% were in plans that were
“underperforming” and received less than 3 stars.
This is our solution?
A solution that is plagued with complex reimbursement systems and unsustainable
costs? One in which the access to care has been severely restricted all in the
name of cost reduction? A system in which patients with insurance are unable to
access the care they need and as a result do not get cost saving, preventive
services. A solution that is only providing average care to the majority of our
seniors?
We know that the cost of care is directly proportionate to
the value it provides, and to be effective, that value must be meaningful to
the patient.
So how much money was invested in 2012 by Medicare Advantage
plans to close traditional gaps, improve access to care and educate patients?
What incentives were paid to primary care doctors who went over and above the
traditional “standard of care” to coordinate, monitor, and deliver care even
during those critical periods of transitions? What about on patient outreach?
Who is calling the member who hasn’t reached out to their PCP after enrolling?
Or, are we only reaching out to those that are over-utilizing services?
Education is the only
answer to a sustainable system.
What training is mandated for HCC Coders? Why aren’t
physicians being taught the underlying principles of risk adjustment instead of
being asked to assign specific ICD-9 codes to their MA members? Where is the
transparency that Obamacare was intended to provide?
What if the answer to our healthcare crisis isn’t in the
millions of medical records we are auditing and re-auditing? What if the answer
isn’t in the “missing diagnosis” codes or the “monetary penalties such as recoupments”?
But, instead in the investment of education for patients,
providers and office staff? What if the answer was creating more flexibility in
the delivery of care or strengthening communities to bring that sense of
responsibility into our neighborhoods? What if we took the money invested in
prosecuting and defending waste, fraud and abuse and redirecting it into
improving access and developing mobile platforms to meet the needs of patients?
Empirical Risk Management was able to create this
personalized, comprehensive, integrated care in our recent pilot program. The
cost of the program was less than $5 per member per month, and the value it
created extended beyond quality measures and HEDIS - it instilled a desire to make better choices.
If we can innovate for as little as $5,per member per month, I can't help but wonder where the other $195 was spent?
