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- Janet on What Sequestration Could Mean to Medicare Advantage Claims Payment
- Kristina on What Sequestration Could Mean to Medicare Advantage Claims Payment
- Curt Black on What Sequestration Could Mean to Medicare Advantage Claims Payment
- Margaret on What Sequestration Could Mean to Medicare Advantage Claims Payment
- Jane Wall Medicare Health Benefits Inc on Strange Bedfellows Come to Medicare Advantage’s Rescue
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Topic: Prospective Evaluations
The New Post-Reform Core Capability for Health Plans: Risk Adjustment
Medicare Advantage and Part D have for years been the world’s largest experiments in paying insurers more for the care of sick members while paying less for healthier members, or risk adjustment. Some two dozen states now risk-adjust Medicaid payments to health plans, and the hundreds of Accountable Care Organizations (ACOs) launching this year and next are risk-adjusted as well. Now that the election has been decided, we know that health plans operating in the insurance exchanges launching in 2014 will also be risk-adjusted based on a similar methodology to that used in MA and Part D. It’s the new core capability for health insurers in the post-reform world, and it’s examined closely by my two top experts, Bill MacBain and Dr. Jack McCallum, in this month’s Managed Healthcare Executive magazine here.
Insourcing: So you are thinking about internalizing risk adjustment . . .
We talk to health plans everyday that want to internalize risk adjustment. Bottom line: It is a good idea.
My Talk at AHIP’s Medicare Conference
I had the pleasure of addressing a standing-room-only crowd at the AHIP Medicare conference yesterday, sponsored by our friends at TMG Health, our 4th year together there. That speech always keeps me on my toes, especially this year – a tough, smart audience that demands a tough, smart message on how to survive in the new Age of American Austerity. Here are the main points of what I said: Read more
Get your money’s worth
When I was a kid, we would jump on those tiny merry-go-arounds outside of stores or those little goofy race cars in Toys R Us and my dad would shake them. Yes, it is true.
Using What You Know to Improve Care for Your Members
In the current issue of the New England Journal of Medicine , a group of physicians from Harvard Medical School describe an unfortunate and instructive case.[1] One of the system’s patients had her spleen removed after an automobile accident. I would venture to guess that just about every sophomore medical student knows that people without a spleen are more likely to have infections, especially with streptococcus pneumonia, and that those infections can lead to death or, as in this poor lady’s case, severe, permanent complications. Anyone who has had a splenectomy should be vaccinated against pneumococcus. So far so good, but the vaccine was never given in this case because the problem list in her electronic medical record was never updated to include the fact that her spleen had been removed.
Consolidation in Medicare Advantage and Prospects for Regional/Local Plans
In the past 12 months three health insurers have each acquired a Medicare Advantage HMO: HealthSpring (Bravo), WellPoint (CareMore), and Humana (Arcadian). Large plans are finding that acquisitions make more sense than investments in organic growth in certain markets, and that enrollment will be driven by millions of plan-friendly Baby Boomers and employers seeking to transfer risk for retirees to Medicare. Investors that sat on the sidelines the last couple years during the financial crisis now need to invest, many large players are sitting on piles of cash, and there are many opportunities in the fragmented MA market. So consolidation will intensify — what does that mean to regional or local MA plans?
Member Evaluations Don’t Replace the PCP
For obvious (and very good) reasons, Medicare Advantage plans want to maximize the unique opportunity afforded by in home evaluations of their members. There is no question that these evaluations can yield diagnostic information that is essential to risk adjustment revenue management. The opportunity to collect clinical information and merge it with data from claims and Medicare return files makes it possible for MA plans to positively influence care in a way that fee for service Medicare cannot. Direct member evaluations also provide a way to quantify and improve measurable standards of care such as those included in HEDIS, ADA standards of care for diabetics, ACC standards of care for cardiovascular disease, and Star ratings.
