I refer to those plans as Medicare Disadvantage plans as well. Seniors who enroll find themselves limited to see certain primary care physicians, certain specialists, a certain radiology group and a certain lab. In my experience there are serious problems. Everything takes time. Sometimes 5 weeks to get a CT scan done. A week for authorization. Three to five weeks to see a specialist. It is not unusual for a patient to wait 6 months from when they notice bloody stool to when they ultimately get their colon cancer resected (as an example). The radiology group is capitated, so getting a CT scan rather than a PET scan saves them money. Missing appointments saves them money. One big group wanted to capitate chemotherapy charges and the amount they allowed per year was 1/4 of the usual cost of good cancer care, so we quit that group. None of these features of having to wait and having good care denied is every discussed with seniors before they sign up. I could go on and on with examples.
Developing meaningful comprehensive clinical outcomes reporting standards in addition to standard cost & “quality” reporting could make the performance of capitation plans more realistic in setting capitation rates. Upcoding must be audited and prohibited without actual outcomes measures and improvement. But, I am sure the privatized MA bandits can find a way to game that too. It is their business model.
It’s also possible that MedPac got it entirely wrong. They didn’t even mention the coding system they attacked was eliminated completely by CMS this year. https://www.intergroupinstitute.org/blog/medpac-got-it-wrong/ That’s a big deficiency in their report.
I investigated the switch into using encounter data, which went fully operational this year. It turns out that encounters can include a home visit, an annual wellness visit, or any other reimbursed consultation that results in identification of a medical condition, whether treated or untreated. Once in the medical record, it can be used to increase the risk-adjustment score. So while using encounter data may make it more difficult to engage in outright fraud, it won't put a stop to using untreated medical conditions to inflate risk scores. A simple example from my own experience (I'm in an MA plan): I have slightly elevated cholesterol, but I don't take a statin because of the side effects. The fact that it is in my medical record means my MA plan receives a higher-than-average payment for me because I'm deemed "at risk" of heart disease, even though it doesn't incur costs for that diagnosis.
The actuarial data already takes that continuum into consideration in doing their numbers. They know the disease severity continuum and the averaging process creates the right number. The system isn’t affected by micro adjustments at the patient level. It just needs to know that you are legitimately in that continuum. That’s the genius and beauty of building the averages from encounters. Relax on the fine tuning.
I refer to those plans as Medicare Disadvantage plans as well. Seniors who enroll find themselves limited to see certain primary care physicians, certain specialists, a certain radiology group and a certain lab. In my experience there are serious problems. Everything takes time. Sometimes 5 weeks to get a CT scan done. A week for authorization. Three to five weeks to see a specialist. It is not unusual for a patient to wait 6 months from when they notice bloody stool to when they ultimately get their colon cancer resected (as an example). The radiology group is capitated, so getting a CT scan rather than a PET scan saves them money. Missing appointments saves them money. One big group wanted to capitate chemotherapy charges and the amount they allowed per year was 1/4 of the usual cost of good cancer care, so we quit that group. None of these features of having to wait and having good care denied is every discussed with seniors before they sign up. I could go on and on with examples.
Developing meaningful comprehensive clinical outcomes reporting standards in addition to standard cost & “quality” reporting could make the performance of capitation plans more realistic in setting capitation rates. Upcoding must be audited and prohibited without actual outcomes measures and improvement. But, I am sure the privatized MA bandits can find a way to game that too. It is their business model.
It’s also possible that MedPac got it entirely wrong. They didn’t even mention the coding system they attacked was eliminated completely by CMS this year. https://www.intergroupinstitute.org/blog/medpac-got-it-wrong/ That’s a big deficiency in their report.
I investigated the switch into using encounter data, which went fully operational this year. It turns out that encounters can include a home visit, an annual wellness visit, or any other reimbursed consultation that results in identification of a medical condition, whether treated or untreated. Once in the medical record, it can be used to increase the risk-adjustment score. So while using encounter data may make it more difficult to engage in outright fraud, it won't put a stop to using untreated medical conditions to inflate risk scores. A simple example from my own experience (I'm in an MA plan): I have slightly elevated cholesterol, but I don't take a statin because of the side effects. The fact that it is in my medical record means my MA plan receives a higher-than-average payment for me because I'm deemed "at risk" of heart disease, even though it doesn't incur costs for that diagnosis.
The actuarial data already takes that continuum into consideration in doing their numbers. They know the disease severity continuum and the averaging process creates the right number. The system isn’t affected by micro adjustments at the patient level. It just needs to know that you are legitimately in that continuum. That’s the genius and beauty of building the averages from encounters. Relax on the fine tuning.