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I run a YC startup that was accepted to Medicare ACCESS.

Historically, insurance has paid for activity: time spent in visits, RVUs generated, and minutes logged. This was a reasonable starting point, but the flaw is that there's no strong incentives to be efficient.

ACCESS is explicitly a "deflationary" approach. Medicare has set the payment rates high enough to be viable for startups, but low enough that you have to use software (including AI) to deliver a large part of your program.

So Medicare has basically created economic incentives to reward software without prescribing the exact shape of the programs. I thought it was a really interesting approach and builds on 15 years of lessons from CMMI (Medicare's innovation group).

3 comments

I would maybe modify this to say - there is a strong incentive to be efficient - you only make so much money per encounter, DRG visit to the hospital, etc. So the pressure from "management" on a lot of us clinicians is to see more people per day, make each hospital visit as short as possible, etc. Medicaid providers now see something like 50-60 patients a day because the per-patient visit is relatively low. But there isn't as much incentive for outcomes. I think CMS has tried it in the past, but with varying success. Whether this new mousetrap will work, who knows.

The existing CPT codes (roughly) pay proportionately to physician time (RVUs). So I wouldn't say there's an an incentive toward delivering care efficiently, but rather hospital management wants to maximize billable hours.

Oh no, there's both. At least for consultations, there's only 3 inpatient / 5 outpatient levels of CPT codes which work for both complexity and/or time. And patients tend to be pretty complex, so it'd not hard to justify a level 4 or 5 CPT code; any less than that and the patient usually has absolutely nothing wrong with them. And at best, max complexity, Medicare pays, something like $227 per CPT code. So to keep the lights on, you'd better figure out a way to see 14, 16, 20 patients a day...a practice cannot stay afloat if you take 45 mins to an hour to see a level 5 CPT code.

For hospital stays, I may be outdated in this, but Medicare pays a lump sum DRG which doesn't tend to go up much, so the longer the patient is in the hospital, the less money the hospital makes.

Short story is the biggest pressures from the higher-ups is for us to see more volume outpatient, and cut duration of stays inpatient....

There are a million doctors in the U.S. so if they're each seeing 60 patients per day that would mean that 17% of the population needs to be seen by a doctor daily.

That would put hospitals somewhere between churches and offices in terms of the impact they have attracting attendance.

That's not what the post you're replying to said, at all.

I'm not in a position to evaluate whether they were right, but you've presented this as if it proves them wrong when it's barely related to what they said.

I'm not sure you understand how the Internet works. I'm here to share thoughts, not to prove I'm smarter than people.

Not all doctors are general practice doctors. I bet surgeons or cardiologists spend more time per patient.

Why isn't this vulnerable to the upcoding problem that plagues medicare advantage plans?

MA upcoding survives because insurers profit from risk-coding patients sicker. if this breaks that link, watch how insurer Medical Loss Ratios shift in 10-K filings over the next 2-3 years

> ...but the flaw is that there's no strong incentives to be efficient.

This was a feature, not a bug. More inefficiency means more profit can be captured.