Medicare HMO News from MCOL May 2018

Key Considerations for Financial Modeling Value-Based Payment Arrangements
Sponsor Message


"Step one of success for Medicare Advantage plans is getting members to take clinical action, starting with going to the doctor to be properly coded for risk adjustment every year and complete Star Ratings-related screenings."
Brennan Collins, Vice President of Product, HealthMine


In 2018, 43 million of the 60 million people with Medicare have prescription drug coverage under a Medicare Part D plan; most (58%) are covered under a stand-alone prescription drug plan (PDP) but a growing share (42% in 2018) are in Medicare Advantage prescription drug plans (MA-PDs), which also provide other Medicare-covered benefits. According to a recent report by Kaiser Family Foundation.
Source: Kaiser Family Foundation, "Medicare Part D in 2018", May 2018

Featured Story

“Owning” the Medicare Patient Relationship
By Paul Gauthier

While 10,000 citizens are aging into Medicare daily, only half that many are joining the pool of the commercially insured. Clearly, caring for seniors is where the action (and revenue) will be in the coming years; and that only goes to magnify the importance to physicians of retaining their existing patients when they turn 65 as well as capturing new slices of the Medicare pie.

The “new seniors” aging into Medicare are being bombarded with messages from competing Medicare Advantage plans that collectively provide coverage for approximately one-third of all Medicare beneficiaries nationwide. Medicare Supplement plans are hitting these seniors hard as well and the battle for policyholders is fierce. Given the marketing savvy of these plans physicians can no longer passively sit on the sidelines and assume that their patient portfolio is secure. Now, more than ever, physicians need to consider a proactive strategy for not just attracting seniors to their practice but – perhaps even more important – retaining current ones. That’s the challenge. The good news is that it is now increasingly possible for a physician to effectively manage his or her Medicare population at little or no cost.

Today a growing number of insightful medical groups are working with outside partners to put together a comprehensive senior outreach program. The most successful of these programs focuses on three main areas: influencing the “turning 65” population, communicating with their existing Medicare patients at the time of a compelling event, and developing a sustainable patient communication strategy throughout the year.

1. Influencing the “turning 65” population – Being successful in this arena involves a well-orchestrated outbound letter, phone and (often) email campaign to existing patients soon to become Medicare eligible. The communication should remind them that most physicians don’t accept all insurance options or health plans; and if they enroll with a health plan their current doctor does not accept, their care may be in jeopardy. The point here is to distinguish this communication from the abundance of marketing materials the health plans send by leveraging the trust, familiarity and equity inherent in the existing physician-patient relationship. Fortunately, resources now exist that can assist physicians in this effort through proven-effective communication strategies.

Central to this campaign is the establishment of toll-free Medicare insurance helpline that connects seniors with licensed agents specially trained to help educate them on their Medicare options, including Medicare Advantage and Supplement plans. In addition to providing information, these agents also help seniors enroll in whatever plan they choose and make it easier for Medicare beneficiaries to find a plan that is accepted by their current doctors. The agent can then serve as an ongoing resource for the senior year after year.

2. Communicating with an existing Medicare patient at the time of a compelling event – The most obvious of these occurs when the termination of a contract between a medical group and a health plan is imminent. Absent of a patient-retention strategy, the health plan will automatically assign the member someplace else. That hurts the patient relative to continuity of care and also hurts the physician with the loss of market share they have often worked many years to cultivate.

Here, too, outside sources now exist that for very minimal fees can assist medical groups with communicating this disruption to their patients while taking the burden of answering insurance questions off of their staff’s shoulders. These sources can explain to patients’ what their options are and provide assistance in enrolling in a plan with which their existing physician is contracted. Such a campaign could include personalized letters, emails and phone calls along with the establishment of the helpline, which can serve as the trusted “go-to” source for free information and enrollment assistance.

3. Developing a sustainable patient communication strategy throughout the year – An effective Medicare retention strategy is an ongoing commitment of making sure that the doctor – not the health plan, hospital or generic website – is the trusted healthcare advisor. Physicians today already have a website and hopefully have email addresses on their patients. It’s time to efficiently leverage these tools to their fullest advantage, whether that be personalized messaging or ongoing electronic communication through an easily pushed-out e-newsletter.

For example, health plans regularly communicate with members, providing reminders to get their health screenings or to eat healthily or to be aware of changes impacting their coverage. Physicians need to take a page from this playbook and not default such communication to the health plan. Why shouldn’t the “time for your annual physical” reminder come from the doctor, and why couldn’t physicians provide the same personalized health information that health plans have become so proficient in doing? To cement a relationship, patients need to become accustomed to receiving their healthcare information from their physician, not their health plan.

Doing all of this may sound like a sizeable undertaking for a physician group that is already grappling with nagging government regulations, shrinking reimbursement from insurers, and new competition from entrepreneurial startups. But by smartly leveraging the road-tested experience of the right outside resources, physicians can level the playing field with health plans and truly “own” the relationship with their Medicare patients as never before.

Paul Gauthier is founder and chief executive officer for MedicareCompareUSA, the nation’s leading independent resource in helping Medicare beneficiaries select a health plan that is accepted by their existing providers.

In The News

Medicare Part D Prescription Drug Plan Discounts And Highlights For 2019
The President signed the Bipartisan Budget Act of 2018 into law on February 9, 2018. This legislation affects Medicare Part D prescription drug coverage. Some of the changes mean discounts for Medicare Part D subscribers, while other changes make for increases in the amount of money that subscribers will need to pay. Forbes, May 16, 2018

HealthMine Releases Medicare Advantage Plan Bid Incentives Checklist
As Medicare Advantage plans prepare to file their plan bid for 2019 on or before June 4, HealthMine has created a starter checklist for member incentives designed to help plans meet success metrics as established by the U.S. Centers for Medicare & Medicaid Services (CMS). PR Newswire, May 16, 2018

Check Out How Much Medicare Spends on Drugs
The Centers for Medicare & Medicaid Services spent $174 billion on prescription medications in 2016, or 23% of its total budget, the agency reported Tuesday. That's up from $109 billion, or 17% of the budget, in 2012. CNN, May 15, 2018

More Competition May Benefit Medicare Advantage Bidding Process
The Medicare Advantage (MA) bidding process requires more competition to increase the availability of high quality MA plans for beneficiaries and reduce federal spending, according to a new Brookings Institute report.
HealthPayer Intelligence, May 14, 2018

CMS Increases Payments for Durable Medical Equipment
CMS has issued an interim final rule that raises Medicare payments for durable medical equipment (DME) to ensure Medicare beneficiaries have access to critical medical devices. The rule will raise DME payments to Medicare providers from June 1st, 2018 to December 31st, 2018 within rural regions not subject to the DME Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). HealthPayer Intelligence, May 10, 2018

ACOs that Take on Downside Risk Save Medicare Money
Centers for Medicare and Medicaid Services Administrator Seema Verma told a group of hospital executives and administrators that taking on downside risk is the way to take cost out of the Medicare system. Healthcare Finance News, May 7, 2018

Humana, Aetna, UnitedHealthcare all cashing in on Silver Tsunami
Aetna, Humana and UnitedHealthcare all reported positive financial results this quarter and executives cited the same reason: swelling numbers of Medicare Advantage enrollees, otherwise known as the Silver Tsunami. Healthcare Finance News, May 3, 2018

CMS Releases New Medicare Advantage Data Resource
CMS Administrator Seema Verma announced a new Data Driven Patient Care Strategy, an initiative that strives to make CMS data more accessible and usable, including Medicare Advantage encounter data. The agency is starting by releasing a preliminary version of the 2015 MA encounter data, with a final version of that data planned for release later this year. Encounter records for subsequent years will be released on an annual basis. Healthcare Dive, April 26, 2018

DOJ investigating Anthem’s Medicare Advantage, Part D plans
The Department of Justice has asked Anthem for more information about its Medicare Advantage and Part D plans as part of an ongoing probe dating back to 2016. The DOJ issued a civil investigative demand to Anthem in March asking for additional information about the company’s “chart review and risk adjustment programs under Parts C and D of the Medicare Program,” according to a Securities and Exchange Commission filing on Wednesday. Fierce Healthcare, April 26, 2018

Provider-sponsored Medicare Advantage Plans Seeing Big Growth in Membership
In an analysis of CMS data released by Axios, Kaiser Permanente dominated total enrollment, with 1.57 million members accounting for more than half of MA members in provider-sponsored health plans. Michigan’s Spectrum Health saw the biggest jump in enrollment (46 percent from 2015 to 2018), while Highmark saw its enrollment drop by 16 percent while still retaining 262,000 members as of this year, putting them No. 2 in total membership behind Kaiser. HealthExec, April 26, 2018


Medicare Could Cover Food, Air Conditioners...Is Sex Next?
American Council on Science and Health, May 3, 2018
Might CMS Move to Implicitly Mandate Health Data Exchange at Discharge, at the Federal Level?
Healthcare Informatics, April 26, 2018


Improving Care and Lowering Costs: The Use of Clinical Data by Medicaid Managed Care Organizations


CMS Administrator Seema Verma on Launch of Improved Medicaid and Medicare Drug Spending Dashboards

U.S. Centers for Medicare and Medicaid Services Administrator Seema Verma describes new updates to CMS's drug spending dashboards, explaining that for the first time the dashboards will display drug prices and year-over-year changes in drug costs for Medicare and Medicaid.

Check out HealthshareTV, the home for health care videos

Definitive Healthcare: Top 25 ASCs Ranked by Number of Medicare Charges
    Tower Wound Care Center (CA): $16,775,282; 96,353 Procedures
    Center for Cardiovascular Research and Education (AZ): $14,175,090; 1,323 Procedures
    Silicon Valley Interventional Surgery Center (CA): $12,200,367; 813 Procedures
    River Drive Surgery Center (NJ): $10,276,876; 11,175 Procedures
    Ophthalmology Surgery Center Of Dallas (TX): $9,360,424; 9,125 Procedures
    Marshfield Clinic - Marshfield Center ASC (WI): $8,856,192; 19,114 Procedures
    Fremont Ambulatory Surgery Center (CA): $8,674,363; 6,877 Procedures
    University Surgery Center (CA): $8,579,856; 3,549 Procedures
    Coronado Surgery Center (NV): $8,475,999; 872 Procedures
    Santa Rosa Surgery and Endoscopy Center (CA): $8,189,857; 6,701 Procedures
    Tyler Cardiac and Endovascular Center (TX): $8,166,091; 642 Procedures
    Surgery Center Of Huntsville (AL): $8,002,772; 12,282 Procedures
    Zion Eye Institute (UT): $7,689,662; 3,144 Procedures
    Seashore Surgical Institute LLC (NJ): $7,664,992; 6,005 Procedures
    Island Eye Surgicenter LLC (NY): $7,648,968; 9,425 Procedures
    GI Diagnostic & Therapeutic Endoscopy Center Southaven (MS): $7,613,695; 22,080 Procedures
    The Heart and Vascular Center (TX): $7,464,732; 570 Procedures
    Eye Center South (AL): $7,367,211; 14,251 Procedures
    Physicians Eye Surgery Center LLC (SC): $7,099,287; 8,654 Procedures
    Atlanticare Surgery Center - Egg Harbor Township (NJ): $6,926,743; 9,194 Procedures
    Medarva Stony Point Surgery Center (VA): $6,924,103; 9,466 Procedures
    Cincinnati Eye Institute - Blue Ash (OH): $6,249,364; 9,845 Procedures
    Wills Community Surgical Services (PA): $6,210,621; 5,984 Procedures
    Copper Ridge Surgery Center (MI): $6,098,252; 11,895 Procedures
    Medical Center Clinic (FL): $6,055,642; 19,299 Procedures
 Source: Definitive Healthcare, May 4, 2018

Check out HealthSprocket, the home for healthcare lists

MCOL - Positioning you for change in health care
1101 Standiford Ave., Suite C-3
Modesto, CA 95350


MCOL respects your privacy.
Please read our online Privacy Policy.