Staying Independent...Together

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   RE: opportunity for imps Please respond?
 From: Peter Liepmann
 To: Member Forum
 Posted: 06-02-2017 23:28
 Message: "Ask for May, settle for June."  Likewise with the capitation amount, ask for 12%, settle for 9%.   What I'm worried about  (a little) is if you get really high risk MCR patients who take a LOT of time, $90/mo won't cover it. Six visits a month, every month? Ouch.  That homebound patient with metastatic cancer could take up a lot of your time for a time- several months, anyway.
If you went for a straight $3/day, unadjusted, for all MCR members, AND you had a large enough group- probably several hundred, that would lower the risk of hitting the jackpot. High needs patients would be proportional to the whole population.  The best of the various risk adjusters account for about 60% of risk.

The reason for the somwhat complicated calculations with HCC, is that it protects everyone- you don't have to overpromise, and it's less likely you'd get taken advantage of.  HCC is how MCR estimates the total cost of Medicare enrollees, and it's probably the best methodology we have.  (United Health Care abused it to get higher payments. Surprise!)

A critical factor is whether CMS considers any APM that goes through PTAC to be "a Medical Home plan expanded under 1115A."  If so, you don't have to take financial risk, if not, the way CMS interprets MACRA, it's an absolute requirement.  Whether or not they require financial risk, you don't have to hold back money for quality risk.  You can reduce future payments.  Makes calculations much easier.

I think CPC+ only included E&M codes.  On another thread, you'll see my attempts to find out.  If someon IN a CPC+ are asked, you might get an answer. I think it would make more sense to include more services, but that would make calculations more difficult.
QLiance included a whole BUNCH of stuff, including minor surgeries, splinting & casting nondisplaced fx's, etc.    Pages 10,11

Jean, how are you putting this together, with whom, and what level of detail?Spending is highly skewed
Almost anything other than FFS, at adequate rates, would be an improvement. Ask for more, settle for less.

Peter Liepmann MD FAAFP MBA
My mission is to fix US health care
Bakersfield CA
Original Message:
Sent: 05-31-2017 19:19
From: Jean Antonucci
Subject: opportunity for imps Please respond?

Thank  you  for doing all that useful homework for me Peter
 For those who want the brief part:  I do plan to submit a proposal for an innovative payment  project that is broadly testable simple and practical,  and easy for small practices The proposal is 2.00 a day with 3.00 a day for high risk patients Risk determined by HYH

Peter  You read and know amazing details
I want to move away from the current complexities However it is useful to hear the comparison to Medicare spending 9000 a yr per beneficiary on average If we get 4% now 30/mo  or about 400 a yr  that  goes along with my  real world capitation figures
 My plan  includes risk by  1 holding practices accountable to  HYH goals(performance risk) but none  of this pay it back stuff  There would be a 15% withhold payable at the end of each yr if goals are met
To avoid having  people just take the money and refer people out  they have to meet performance goals and probably panels would be capped.
This is only about primary care  services not what  you call total  capitiation I cannot take on costs of hospitalization or medds  etc

I will have to see what primary care services are in cpc+    Mike thank you for chiming in

People will have to submit  icd 10 codes but no cpt codes I hope

I do not want to  play with HCC codes they are an odd contrived way to make patients look sicker


     Jean Antonucci MD
     115 Mt Blue Circle
     Farmington ME 04938
ph 207 778 3313   fax 207 778 3544

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