Overachiever: So, what happens when the healthcare system starts having unparalleled success in value-based arrangements? What, for example, do insurers think will happen to the target baseline on which a physician is measured, and will insurers share more savings or less? Thoughts here from our poll.
Revenue Short: There’s been a little reported issue between reimbursement for Medicare Advantage patients vs. fee-for-service Medicare. While traditional Medicare has allowed providers the discretion to waive cost share during this pandemic, that will come out of the provider’s books as uncollected revenue. In contrast, some, if not most, MA payers have waived copays for newly expanded telehealth visits, and MA payers are increasing their payments to providers to compensate them for the copays that are not being collected, essentially “making them whole”. We’ve found from dozens of providers we’ve talked to that MA plans are generally “making them whole” by paying the rate for the service, then providing the waived copay portion of the service through a second “remit” a few weeks later. But fee-for-service Medicare “is not making us whole,” sources say. “We basically are trying to collect the copay, but if the patient says they can’t afford, we just waive – it’s not a big deal with MA, but if it’s a fee-for-service patient, that’s been 20% less revenue,” one administrator said.
77: Percent of employers in our February poll of 219 small, midsize, and large companies who say the time to diagnosis for pain and orthopedic issues is “excruciatingly slow” and “wasteful,” and has led to issues with “presenteeism, productivity” and ultimately higher health cost spend per employee. “Not just lower back pain, but neck pain, knee pain, upper back, elbow – we have been pressing in recent years to use PT first for several weeks but sometimes an X-ray is needed right away to rule out issues,” says Dave Simmons, a medical director consultant for self-insured employers.
Oh, the Worried Well: If there’s one delivery model set to face some turbulence between now and 2025, it may just be urgent care. Click here to read why and how.
Caregiver Decline: Caregivers were already reporting mental stress and physical health declines before the pandemic and now it’s escalating, according to sources. Back in the Fall, 91% of those caring for a senior family member with a condition like dementia, Alzheimer’s, or cancer reported mental stress, 75% reported depression, and 27% said they had gained weight. Brigid Byrne, who cares for her 90-year-old mother who has cancer, along with her grandson, says there’s “lots of stress and worries, but lots of laughter.” There may be limited support from health providers or insurers but there are local and national networks online to support caregivers, like the Caregiver Action Network. Others say they have grandparents who have deteriorated when left to care for themselves, particularly when their spouses can’t help them, or they move out to assisted living or nursing facilities. “He’s absent a lot even when he’s in front of you...a lack of physical activity is a problem,” one research participant tells us about his 88-year-old grandfather. Using iPads and other technology is “nice to have” but doesn’t solve depression or mental health, and in some cases these things can exacerbate it. For the healthcare community, solutions are difficult because they require consistent attention, one-on-one services, commitment, and perhaps new payment strategies from insurers. More here.
Top 10 Innovations: New technology is emerging in every industry but healthcare, in particular, is booming these days with new apps, robots, and telehealth initiatives designed to revolutionize diagnosis and treatment. In this piece we published back in early February, several themes resonate even more now given the pandemic. Check out the Top 10 here.
Glidepath to Risk: In case you missed, just because there’s a pandemic doesn’t mean risk contracting has stopped, interestingly, as we’re hearing more payers and providers continuing to explore risk contracts. And why not? With the downtick in visit volume, it’s not a bad time to be getting capitated payments if you’re a provider. In discussions we’ve had this week, several suggested that they are finding some success with upside only arrangements, essentially an FFS payment or flat cap with a “glidepath” to risk, which is basically a way to limit exposure as the practice learns how to manage operations–and patients–in a new payment model. One idea is to set up the contract as FFS or flat primary care capitation and agree to share in the surplus or savings, typically 50%, but at 0% exposure to deficits. Then, as several noted, you move to a full global risk capitated payment the following year, like in 2021 as some have done. “This gives us time to acclimate, to code up patients who should be coded higher based on acuity, to get the premium to the appropriate level,” one payer contracting director noted. Most sophisticated MA payers are typically on board with glidepaths, as they do not want to see a provider group rack up deficits during the learning curve. Other providers tell us they have had some success convincing the insurer to agree to an “early switch to cap or risk” before 2021, if they are finding success. “One MA plan was a little unsure but agreed to changing to full risk earlier than the 12-month glidepath if we are doing really well.” This “early flip” language allows the practice to stop giving away the 50% surplus back to the payer when they could be gaining the whole surplus, though it will have to prove it is meeting “minimum thresholds” of attributed members.
Extra Point: ER doctor Lorna Breen saved hundreds of lives recently but the tragedy around her at a New York hospital was too consuming. Last weekend, a few weeks after getting the virus, trying to return to work but devastated she couldn’t, she took her life. She is still a hero in my book. Breen’s end is not her story. It is that age-old story of striving to put others first – and sadly in this case, succumbing to an overwhelming feeling of helplessness. Erin Golden is also familiar with putting others first. She’s a cancer survivor two-times over, battled addiction, surgeries, raised a son, and has been trying to re-start, but has spent the last two months coordinating health and wellness care for her older parents. She is us. Golden’s 86-year-old dad was in the hospital for a week with presumptive coronavirus, had a fever and pneumonia, “so we expected the worst,” she told me. Test results were negative but two weeks after quarantine at home, Erin’s mom got a fever, went to urgent care and the staff there said, “we don’t know why you have a fever.” There was no test available. Golden admits she’s lucky and has been doing what many of us are trying: setting up a healthcare support system and network at home for our folks. We bring my 82-year-old mother-in-law into our home this week. With severe dementia, she’s a flight risk, but in a silver lining the virus will give our kids time with nana they wouldn’t have.