What You Need to Know
About Medicare
Advantage
2016 Annual AMGA
Conference
Ken Cohen MD, FACP, CMO
New West Physicians
Who We Are
• Since our inception in 1994, New West Physicians has grown to
become the largest physician-owned primary care group practice in
Colorado
• Family
practice,
internal
medicine,
hospitalists,
physician
assistants, nurse practitioners, behavioral health, cardiology,
neurology, endocrinology, and gastroenterology
• 95 providers
• 17 offices throughout the Denver Metro area.
• 300+ Employees - $58M Revenue
Quality
• In 2011, the American Hospital Association commissioned a national
study on Accountable Care and chose four delivery systems
representing different models of care. New West Physicians was
chosen as the primary care model for that study.
• In 2013, New West Physicians received the Colorado Best Practice of
the Year Award by the Colorado Academy of Family Physicians
Foundation.
• In 2015 the AMGA awarded NWP the Acclaim Award for the
organization which most closely approaches the ideal health system
as measured by the IOM “Triple Aim”
NWP and Medicare Advantage
• 12% of our total patient volume represents 40% of
total revenue
• Average income in NWP is ~75% higher than
Denver metro average
• MA bonus accounts for ~30% of average income
Population Health Management
EHR with Data
Timely
Feedback to
Physicians
Care Mgmt
EvidenceBased
Guidelines at
Point of
Service
Patient Centered
Medical Home
Access
Patient Portal
Team-Planned Visits
Care Coordination
ACO’s
Management of Full
Continuum of Care
Comparative Effectiveness
Emphasis on Cost & Quality
Remunerative Mechanisms
Essence of Population Health Management…..
Achieving the simultaneous goals of:
The delivery of high quality care
The ability to provide high levels of patient service
The elimination of wasted care
Population Health Management
Primary
Care
Specialty
Care
ER and
Urgent
care
Hospital
Care
Post
Hospital
Care
Transition
SNF
Care
Palliative and
End-of-Life
Care
Two Keys to MA Success
• Culture Supported by Infrastructure
• Attention to both revenue (premium) and
expenditures
Revenue Side of the Equation
Premium = RAF + CMS Star Rating
RAF – Critical Importance
• Patient A – healthy 65 year old – annual premium
from Medicare
– ~$6000
• Patient B – 78 year old with diabetes, congestive
heart failure and peripheral arterial disease –
annual premium from Medicare
– ~$26,000
•
•
•
•
76-year-old Female
Medicaid Eligible
Diabetes
Chronic Kidney
Disease Stage 5
• Ulcer Right Great Toe
Health Status/DX
Code
HCC
RAF
Score
76 YO Female
NA
0.457
Medicaid Eligible
NA
0.131
E11.9
018
0.368
N18.5
136
0.224
L97.513
161
0.536
Total RAF
1.716
Health Status/DX
Code
•
•
•
•
•
•
•
•
•
•
76-year-old Female
Medicaid Eligible
Type 2 Diabetes w/ Diabetic
Chronic Kidney Disease
Chronic Kidney Disease Stage
5
Dialysis Status
Type 2 Diabetic Angiopathy w/
Gangrene
Arteriosclerosis of Right Leg
with Ulceration of Other Part of
Foot
Ulcer of Right Foot Great Toe
with Necrosis of Muscle
Amputation Status Left Great
Toe
Insulin Dependence
HCC
RAF
Score
76 YO Female
NA
0.457
Medicaid Eligible
NA
0.131
E11.22
018
0.368
N18.5
136
0.224
Z99.2
134
0.476
E11.52
018
0
I70.235
106
1.413
L97.513
161
0
Z89.412
189
0.779
Z79.4
019
0
Total RAF
3.848
Health Status/DX
Code
Total yearly premium for
first example = $14,300
Total yearly premium for
this example = $31,500
Same patient/same
diagnoses – it’s all in the
coding!
HCC
RAF
Score
76 YO Female
NA
0.457
Medicaid Eligible
NA
0.131
E11.22
018
0.368
N18.5
136
0.224
Z99.2
134
0.476
E11.52
018
0
I70.235
106
1.413
L97.513
161
0
Z89.412
189
0.779
Z79.4
019
0
Total RAF
3.848
RAF Optimization
• 1 on 1 Provider Education
• RAF reference desk tool
• RAF Tips of the Week
• Quarterly reporting to all PCP’s
• Yearly RAF sweep for missed codes
• Portion of individual bonus tied to RAF
• Coder feedback to providers
CMS Star Program – Overview
• Plans rated at 1-5 stars – no bonus if 4
star threshold not met
• Currently at 0-6% of premium
• $1.3 million per 10,000 lives if 4 star
bonus achieved
Expenditure side of the equation
• There is no relationship between cost of
care and quality of care
• More care does not equal better care
Wasted Care
• Wasted care is care that does not improve
health outcomes or quality of life
• Estimated at 35% of all HC expenditures
Why Medicare Advantage?
• Largest pool of wasted care is in the Medicare
population
• Elimination
of
wasted
care
and
quality
improvements translate directly into improved
patient care and bonus revenue to the group
Wasted Care High Frequency
Cardiology
– Asymptomatic CAD - Nuclear stress testing
– Preoperative evaluation – Nuclear stress testing
– Mild to moderate valvular lesions – echocardiogram
• Gastroenterology
– Colon polyp follow-up guideline
– Barrett’s esophagus screening
• Pulmonary – Low risk lung cancer screening
• Dermatology – Mohs for small basal cell cancers
Wasted Care High Cost
• Urology – prostate cancer screening > 70 yrs
• Orthopedics
– Lumbar fusion for osteoarthritis
– Arthroscopy in advanced knee DJD
• Neurology – screening for asx carotid stenosis
• Oncology – futile care for advanced cancers
• Lucentis/Eylea for macular denegeration
In Summary…
Why Medicare Advantage
• Largest pool of wasted care is in the Medicare
population
• Elimination of wasted care translates directly into
bonus revenue to the group
Opportunities
• Improved patient quality and service
• Improved coordination of care
• Significant bonuses are achievable
• Autonomy from hospitals and health plans
Who Will Succeed?
• Culture is critical
• Shift from patient to population management
• Comprehensive care at all levels and locations,
and across all specialties
• Accurate, timely and actionable data
• Focused case management
• Equal attention to both quality and utilization
• Aligned compensation model
Thank you and
Opportunity for Questions
The mission of New West Physicians is "to enhance the physical, mental and
spiritual health of communities we serve through an integrated, primary-care
owned and patient centered healthcare delivery system."