So many of the challenges of the organizations I consult with could be fixed with a little clarity.
Health systems put a lot of pressure on their primes to control costs. They alienate their Medicare Advantage enrollees with that pressure as well.
Most “stop-loss” insurance for Medicare Advantage contracts pay 90% of losses after a $10,000 deductible, and 100% after the losses hit 100k. There’s some variability in benefits but that’s pretty much average.
So all the effort you’re putting in towards controlling costs is actually being put towards controlling $20k a year in losses per patient—and keeping the pmpm premium costs of that stop-loss reinsurance low. Both can be easily offset by positive revenue from other Medicare Advantage beneficiaries.
Saving that 20K and an extra nickel on your PMPM premium really isn’t that much of a gain compared to all the heartache and discouragement your efforts are infusing into your medical staff. And if your efforts result in you losing even one patient, your overall financial performance suffers.
So how about this—let your primes control the care costs as best they can. Don’t harp on them or give them negative feedback. It’s just not worth the potential return.
I’d take a good long look at care management too. It may be best off-loaded to your insurance partner.
Concentrate instead on keeping your workforce happy and keeping their patients bonded with their primes.
The value you generate will flow a thousand-fold.
And it will cost less, too