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:

• Volatility and Accountability will define the sext several years in Medicare.  Volatility: rates, the Medicaid dual eligible explosion, the Congressional “Super-Committee”, industry consolidation, and the 2012 elections.  Accountability: it’s already here.  Star Ratings bonuses, minimum MLR regulations, compliance, rate reviews, RADV audits, and Accountable Care Organizations. 
• The State of the Union in Medicare Advantage (MA) and Part D is strong.  All predictions of the demise of the program following health reform were wildly premature.  MA will grow about 7% this year, and over 40% of beneficiaries aging into Medicare have chosen MA in the last two years.  Local PPOs with the drug benefit integrated remain the product of the future in MA, as do Special Needs Plans given the tsunami of dual eligibles — a $300 Billion market alone.  We think MA will pass 15 million members by the end of 2015.
• Medicaid managed care is risky (BIG) business. We’ve already seen major awards this year in TX, LA and KY.  CA is prepping the biggest RFP in US history: 150,000 duals in plans by end of 2012; all duals in plans by end of 2015: a $21 Billion opportunity. WA, FL, NH, NE, MI and HI are all preparing to move duals into plans. 
• Volatility: many of us thought we “gave at the office” in health reform when the ACA whacked over $120 Billion from MA rates over a 7-year period.  There’s more austerity to come from the Congressional “Super-Committee” on the debt.  Best case scenario? The Super-Committee fails, sequestration occurs, and we get hit with a 2% cut in 2013, 2014 and 2015, compounded.  And what about the “doc fix”? If they don’t fix the SGR and docs take a 29.5% cut in Medicare reimbursement in 2012, MA gets hit by about 7% in 2013, and the beneficiaries take it in the shorts.  Bar the exits! Consolidation is intensifying in both payer-payer transactions, and payer-provider deals like United/Monarch (CA).  And then there’s the elections.  My money as of today is that Obama gets re-elected by the narrowest of margins, Democrats lose the Senate, and we have another 4 years of economic doldrums with the HUGE exception of the ACA’s implementation in 2014. 
• Accountability: it’s already here, a cornerstone of the ACA.  It’s embodied throughout, in Star Ratings bonuses, Accountable Care Organizations, with growing incentives for chronic care improvement, member satisfaction, and compliance.  The cornerstone is transparent data reporting.  Berwick’s legacy will be his embedding the “Triple Aim” in the DNA of CMS.  And CMS says it will terminate MA plans with less than 3 stars for 3 years running.  A “good” star rating is not a hedge against the rate cut: it is an existential issue — and a management revolution.
•   What to Do?
  • Aggressive revenue management in the near term.  Master risk adjustment and audit-proof the function by embedding it where it belongs in Medical Management, move from claims extracts and chart reviews to Prospective in-home Evaluations, and be a Star Czar.
  • Care coordination and chronic care management over the mid-term (3 years).  It will take years to see results, but this is what it’s all about in the mid-to-long-term.  High-touch with the frequent flyers. 
  • Commit to a Culture of Compliance.  The regulator is the purchaser, and you keep this account happy by following their rules.  To. The. Letter.
  • Revisit the service model and move from reactive to proactive.  Health care is still a service business and Boomers are tough customers.
  • Establish and Invest in Medical Homes, Accountable Care Organizations, and Exclusive Provider Organizations.  In the end, it’s all about the docs.

Questions? You can always reach our team at ghg@ghgadvisors.com.

 PS Join me for another talk September 25-26 in Arlington at the Opal Events MA Strategic Business Symposium. Complimentary passes are still available today.