Accountable Care Organization

Episode 45: Confronting Concerns About Medicare Advantage

January - February 2023

Recent news coverage has revealed abuses of the Medicare Advantage program and caused some providers to express concerns about participating in it. In this extended episode, LincolnHealth’s Tim Goltz, MD, joins us to discuss the ethics of the ACO’s and MaineHealth’s approach to the program and the sometimes difficult path toward realizing the promise of value-based care.


Heather: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization. A delicately poached monthly podcast for health care providers. I'm Heather Ward.

Mike: And I'm Mike Clark. Heather and I are practicing physicians who participate in the MaineHealth ACO.

Heather: This month we have a special episode that features just one segment, a Meaty Topic discussion of one of the hottest topics right now among providers at MaineHealth and the MaineHealth ACO.

Mike: Oh, that's a good teaser, Heather. I don't want to delay the big reveal, so let's get right to it.

Heather: We have a very Meaty Topic this month. We're going to discuss the ethics of participating in Medicare Advantage plans through MaineHealth's new BHiVe partnership. And we'll expand that to shed some light on value-based care, the reimbursement model that Medicare Advantage is based on.

Mike: That's right, Heather. But first, some background on BHiVe and on value-based care. BHiVe stands for Building High Value, and the partnership involves MaineHealth, the MaineHealth ACO, and agilon Health. The goal is to accelerate our transition to the value-based care reimbursement model by first focusing on our Medicare Advantage contracts.

Heather: Right. Like all value-based care arrangements, Medicare Advantage plans are meant to incentivize high value of care instead of high volume of care. The mechanism is pretty complicated, but it basically comes down to insurance companies assessing how sick a patient population is and creating a budget based on how expensive they think appropriate care for those patients will be.

Mike: Yeah. So if your patients are sicker, you get a bigger budget to care for them. Less sick, a smaller budget.

Heather: And here's where the incentives come in. If you provide more care than the budget provides for, you eat that additional cost. That's known as downside risk. But if your cost of care comes in below budget, you get to share in the savings along with the insurance company. That's upside risk.

Mike: That's right. So now you might be thinking that this sounds a lot like the old managed care model, especially if you practiced in the nineties, but it does have some similarities. But there is one key difference Heather. To share in any savings, you must first meet stringent targets for quality of care and patient experience. So that's just a safeguard against the under treatment that sometimes happened in managed care.

Heather: Yeah. So when value-based care works as designed, the cost of care comes down while the patient experience and outcomes improve. That's what we're striving for in the BHiVe Partnership and in our Medicare Advantage contracts.

Mike: Yep. A noble goal, for sure. But recently, some abuses of the Medicare Advantage program have come to light that undermine that goal. In some instances, insurance companies have pressured or even paid providers to make their patients look sicker than they really are, thereby increasing the budget for caring for them.

Heather: Yeah, and that sounds really bad. This is naturally concerning and has prompted some concerns about the ethics of our participation in the Medicare Advantage program.

Mike: Right. And add to those concerns some confusion about value-based care in general. Well, we thought it was time to have an open discussion about these issues.

Heather: Right. So let's do it. Joining us for the discussion is Dr. Tim Goltz. Tim is a veteran primary care physician at LincolnHealth who is highly respected for his professional integrity and his dedication to patients and quality.

Mike: Tim, also, I think it's fair to say, was an early critic of the BHiVe Partnership and who has, after a lot of thoughtful research and exploration, become an active supporter of the partnership. Thank you for joining us, Tim.

Heather: Yeah, thanks for joining us, Tim. This is fantastic to have you here.

Tim: Well, it's my pleasure, Heather and Mike.

Heather: So I'm really kind of curious Tim, you must have gotten an earful at times, considering how involved you've become in helping MaineHealth and the ACO participants become more successful. Understanding what the MA program is. I'm kind of curious to know what you've been hearing from your colleagues.

Tim: Well, yeah, so I would say that I've been hearing a number of different things from colleagues. There have been a handful of colleagues who have been highly concerned about our work with the Medicare Advantage programs and have wondered about the ethical issues and whether it's right for us to do this work at all. I think most people have been more curious and interested in what's going on, and I think a lot of people are still maybe somewhat confused and don't understand exactly what we're trying to do now, and also don't have a clear picture of what the potential is going forward.

Heather: Maybe we should talk about that for a second and just kind of lay out there, really, like, what's our goal? Why are we involved with MA programs and value-based care?

Tim: Sure. So I think that in my mind, there's basically two reasons to be involved with value-based care. One is that it allows us to clearly identify the range of health issues that our patients and those programs have and will increasingly allow us to tailor services for those patients so that they can receive the best care possible and as much as possible, stay out of the hospital and have both better personal experiences and lower costs of care for them. Then there is the side where, for years, I know for myself and for probably almost all my colleagues, we haven't been coding things in a way where we get as much revenue as possible from the insurance companies. And my understanding is that across Mainehealth, we've been leaving literally millions of dollars a year on the table.

Heather: Yeah. So for me, I think for value-based care, I'm super excited about being able to understand the needs of our patient population and start thinking about their health before they land in my office. I would love to be able to use some of that money that we are able to get from the value-based care programs and be able to use it in a way that helps really with primary prevention of illness so that we're keeping them out of the doctor's office, not just out of the hospital. For me, that's what I find to be really exciting.

Tim: I do, too. Heather and I attended a meeting with a number of other practices that have been working for much longer with value-based care and heard a lot of examples of exciting things they're doing with having more nurse care managers working to actually decrease the number of patients that primary care providers have on their panels so that we can focus more on preventive long term care for patients. So I think there's a lot of exciting things that are on the horizon. I feel like there's a lot of people within MaineHealth who are being very thoughtful about trying to map out how we can improve the care for our patients who are receiving Medicare Advantage plans.

Heather: Mike, have you been hearing anything? Not just like the kind of positive side of things, but are you hearing concerns?

Mike: You know, I think the concern most providers carry where they worry about the focus, is this, in other words, is this all about the money? Am I being asked to do almost clerical work or I don't know what the right term is, but non-clinical work that focuses on filling in squares and checking off boxes to optimize money that goes where I don't know where it goes, kind of thing. So I think as a practice owner, obviously I feel closer to the revenue stream that comes from the work that I do. So I have a pretty strong feeling about that, especially as a primary care doc, which is not the most lucrative corner within the health care enterprise. So part of my response to that is, I have never felt and I don't think many of my colleagues have ever felt that the CPT or E/M I should say coding actually represented all of the work that I do on behalf of my patients. Trying to distill all of the complexity of an office visit into was that 13 or 14, a 99214, or all the phone calls and other work that really mattered or the time I spent in the chart to do the problem list, cleaning up problem lists, or doing all the things that really accompany complex work on behalf of our sickest patients. We could never really represent that in the E/M coding that we've always depended on. So, I feel like this, yes, this is checking squares and trying to get the ICD-10 codes picked out perfectly and it feels burdensome, but I feel like it's directionally, it's the right work, right? It gets us to that place of trying to understand our patients and the burden of illness, so to speak, or the complexity of their illness, and then hopefully begin to shift the payment system to align with our patient's actual needs. And yeah, I think the journey there is painful and sometimes leaves us scratching our heads, but I feel like it's the correct journey.

Tim: Yeah, I would agree with you. I mean, again, at this meeting that I attended, I had several conversations that the fee-for-service system we know has a lot of problems. What we're currently doing with value-based care, I think is moving us more in a direction of where we want to be. It's not perfect. It's not necessarily the end result where we want to be forever. Personally, I'd love to see us have a single-payer system and really just be able to purely focus on patient's needs and not think about the finances at all. Yes, but I think that this is moving us, as you said, in the right direction.

Heather: I totally agree as well. And I can also say, you know, with a little bit of experience taking care of patients with COVID and then using PAXLOVID and covering a bunch of patients that were not mine, having more detailed problem lists that were accurate actually ended up being very helpful and continues to be helpful when I'm in that situation where I realize how sick or how complex a patient is by quickly glancing at the problem list as opposed to figuring out at the end of a 30-minute phone call and changing my mind based on one piece of information or pieces of information as it falls into place, completely unrelated to value-based care, but certainly in support of having an accurate representation of the complexity of our patients in our diagnoses that we choose.

Tim: I have always been passionate about problem lists and I have a reputation for that.

Mike: Yes, he does.

Tim: Sometimes it annoys some of my colleagues. I think that that is critical for being able to provide high-quality care. And I think that again, the work that we're doing on value-based care is again moving us in the right direction with that. I would say that currently, the work that is happening is primarily falling on the shoulders of primary care, and I'm excited about trying to expand this work so that our specialist colleagues can also work on improving their problem lists and join us in these efforts.

Heather: Yeah, I agree. I think sharing the burden of accurate documentation throughout the entire group of providers caring for our patients would be ideal. Can I shift gears a little bit and touch on something that might be a little bit racy here? And that is the ethical questions that might come to us around Medicare Advantage programs. There's certainly, like you mentioned, Mike, all that concerning news around MA programs. I know from my perspective, I have absolutely had concerns from providers worrying about participating in a payment system that has all this controversy around it in some of the areas around it. So just kind of curious from both of you, what you've heard and what your thoughts are on that.

Tim: Well, I would say that I have had a handful of colleagues who have expressed concern about the ethical issues. There was a very good article a few months ago in The New York Times looking at some of the ethical issues. And when I read through that article and compared it to the work that we're doing here with MaineHealth, it seemed like there were some really significant differences between what's happening in other parts of the country and what we're doing here. And I bring to this a perspective where I am a full-time practicing family physician. I'm also someone who is doing chart audits, and I also function as the pod leader for the primary care group in my office. So I'm seeing this from a bunch of different perspectives. I don't see anything that we're doing here that seems unethical to me at all. Now, in the New York Times article, there were plenty of unethical things where people were being encouraged to code diagnoses that patients didn't have, and then individual providers were getting payments because of coding the inaccurate diagnoses. Not only are we not doing that, there is so much emphasis in our partnership working on Medicare Advantage to reinforce that we want super-accurate diagnoses. And if someone has something on there that is no longer a problem, get it off the problem list, remove it. So, I think the concerns are valid, but I just, I don't see evidence of anything that's happening on any level with MaineHealth where unethical things are either happening or are planned to happen.

Mike: Yeah, I would like to reinforce that too. As a non-MaineHealth employed provider. We've been working on this, I participated in education around accurate coding or aCDI initiatives. We've all received information, right, from the insurance companies asking us to consider diagnoses, not telling us we have to do it, but telling us to consider a lot of diagnoses. So there's been a lot of these different streams of education around improving the accuracy of our coding. It hasn't been until this current collaborative that I've had clear education about removing things from problem lists and making sure that I wasn't representing complexity inaccurately. I've had much more information with our current efforts that have led to me to take things off of problem lists. So, I really too Tim, I really feel like there is sort of a laser focus on accuracy and within our documentation, all the while understanding how success, if I can use that term, works within the structure and the contours of the current MA payment program. So understanding that and how to do that well does not have to, to my view, be at cross-purposes with honest, clear, accurate coding that will ultimately benefit our patients and power us to provide care, especially as Heather, your point about when we cover for each other or when our patients are our care is looked at, maybe from a care manager or nurse care manager or somebody else who participates in the team. I feel that we're on the right path when it comes to the potential ethical issues that come up.

Heather: I totally agree with you on that. I feel like it is absolutely my decision while taking care of my patient to put a diagnosis on a problem list. And it's also my responsibility to clean up that problem list and to remove a diagnosis as well. And I think that, again, it's back to accuracy. I think it's so important for us to accurately represent our patient population, and knowing that if we have a more complex patient population our reimbursement will be better, I think for some people that part might be a little hard to reconcile.

Tim: I agree with you, Heather, but I think what people hopefully can appreciate is that when you're coding people's problems accurately, what you're doing is identifying those patients who are going to incur more expense for their care and making sure that our organization gets paid appropriately for that. Because if we leave off important diagnoses and then the patient winds up spending a few months in the ICU, it's challenging to pay everyone's wages and keep the lights on.

Heather: Yeah, absolutely. And I think that that's an important thing that we sometimes forget about. I think as primary care doctors, we are so comfortable with dealing with complexity and preventing complex problems, we forget that if we don't record what's going on and everything that we're thinking about and treating, now in this value-based system, we're not getting paid for the potential problems. And if I do a great job and I keep my person on anticoagulants from falling because they've gone through physical therapy and they've had strength training and balance training and they never fall and they never have a complication from the anticoagulation, great, that's where we needed to have anticipated that problem and have it documented well. To get paid appropriately for the complexity there. I'm wondering if we can take a step back here for a second and just talk for a minute about the basics. We talk about coding and I'm wondering if we can just spend a minute talking about codes, HCC codes, what a RAF score is. Why do we care about it? And maybe even what is value-based care in relation to coding and RAF scores and patient complexity? Tim, what do you think about, like what do you think about having just dived into this? How do you think about...?

Tim: I would say that despite my level of involvement, I recognize that there's a lot that I don't know yet and there's a lot that I still have to learn. But what I do appreciate now, and I didn't necessarily appreciate a year ago, is that there are really good reasons that we should be specific with the diagnoses that we're putting into patients' charts so that they're both as accurate as possible and so that we get the appropriate amount of reimbursement for caring for more complicated patients. So, for example, a year ago, if you asked me, I'd say, well, everybody can just have type two diabetes without complications on the problem list. And that keeps it simple and I'm not going to worry about other things. Now, I try to, you know, I'm aware what complications are legitimately associated with diabetes. I try to make sure it's exactly coded the right way for each individual patient. And I think that that serves this dual purpose of making sure we get paid correctly and that it is more precise information in the chart that allows us to provide better care for them.

Mike: I think when you brought up the word dual purpose that was an important concept for me. We're used to our diagnosis codes speaking to other clinicians, right? To either ourselves or we view a chart. Those diagnosis codes having to do with thinking about a disease process, but in a value-based care environment, those codes, those ICD-10 codes communicate with the payers of the health care, and they use those codes for an actuarial analysis to help understand how much money needs to be set aside or budgeted for the care of that patient. And so so there's an opportunity both to convey clinical information to the health care enterprise, but also to accurately represent the patient to the payers who have to create an annual budget for that patient. And so our care then, the services we're able to provide are tied to that budget directly. And so it is a chance to secure adequate resources for the care of our patients linked to their complexity, not just to one episode of care, where I did a 99214 versus a 99215.

Tim: And the other key point that I think I had heard before, but it's really been reinforced for me is that magically on January 1st, patients go back to being perfectly healthy. And until we diagnose and code for conditions in a calendar year, the insurance companies think that they have no health issues whatsoever. So we have to make sure that every year patients are seen and the right diagnoses are coded.

Mike: Which I know is maddening because it doesn't pass the common sense test, the example we always use of the amputated limb does not regrow every January 1st. My understanding is part of the method behind that madness is actually to force us as clinicians to review all of the problems on our patients' problem list and to grapple with their implications and to consider what's going on. And part of that is to remove things like the acute stroke that doesn't keep happening again and again, but happened in the past and now is history of acute stroke. So, you know, there are so many things I know that drive us crazy in our day-to day-work, but there's always usually an explanation for it.

Heather: I think that's a really good observation. I feel pretty frustrated every time. I'm like, Oh my gosh, it's almost December 31st. I finally got through 97% of my patients. And I have acknowledged those codes or removed those codes, and I get to start over again on January 1st. But I do love the idea of starting with a fresh palate and just like being able to say like, nope, this is gone, this is better, this is history of. It would be amazing one day to not have a whole lot of HCC codes to go back and think about.

Tim: And the other thing too, is that we have to remember that this is a team sport. The work that our specialist colleagues do helps out with it. We don't have to put down all the diagnoses. If they see a cardiologist and the cardiologist codes for the right type of heart failure, that counts. And that's off our plate for the year. Again, I'm hopeful that in this year we can do more engagement with our colleagues so that we can all work on this together.

Heather: And I think that will be essential for longevity of everybody involved. So we've been talking about so much kind of secretarial work that we've all been focused on, like making sure that the care that we are doing is documented correctly through appropriate HCC codes and removing codes that aren't there. It feels like a lot of administrative work to do right now. What do you guys see as the future of this partnership, the future of our experience in value-based care? Will we always only be doing this administrative stuff or are we going to see changes in how we practice medicine in the future?

Mike: I see opportunities to begin to bring in financial resources and payment into the health care enterprise on behalf of our patients to help pay for things that aren't as easily reimbursed or aren't as lucrative, if you can use that word, in the fee-for-service system that we primarily still live in. For instance, I think if we represent the complexity of our diabetes patients and are successful in preventative care, there's more funding on the prevention side, I think our current system continues to reward when our patients are at their worst or their sickest when the when the tragedies happen, and we don't we've never had enough resources poured into the front end to help with prevention and physical therapy or strengthening or diet counseling or just all of the pieces that just don't have paid as well. But I think, my hope is as we're successful in this, we create a revenue stream into the system that is not tied to these highly expensive, currently highly reimbursed procedures or sick care. It can be well-care, wellness-focused care reimbursement. That's my hope.

Heather: Yeah.

Tim: Yeah, I totally agree. A colleague from another group who has been working with value-based care longer than us shared a story that was really meaningful to me. She talked about a patient of hers with some mild cognitive impairment who had a fall down some stairs and wound up having a fracture of her cervical spine. And she talked about how a few years earlier the immediate reaction would have been send the patient to the emergency room. The patient would have had surgery, would have spent time in the hospital, and then spent time in a skilled nursing facility and probably would have had some issues with delirium and other complications. Because of the resources they had from working with value-based care, they were able to take a different approach where a care manager was able to be involved right away. They looked into resources and they were able to identify a neurosurgeon who had especially good ratings. They got the patient in with a neurosurgeon that day. The neurosurgeon was able to decide that this patient actually didn't need surgery. It could be managed as an outpatient. They're able to get some extra resources into the patient's home. She stayed home the whole time. Her fracture healed. Life went on. You know, it was really moving to think that there are different ways that we can do things that are better for our patients and make us feel better about the work that we do. So I think, yeah, right now we're into a lot of stuff that's not necessarily the most exciting, but there's definitely light on the horizon about really neat things that we could be doing to provide better care.

Heather: I think it's important for us to look to that. It's really exciting.

Mike: That's a great story, Tim. Thank you.

Heather: Yeah.

Mike: That sort of future state or that place where wouldn't it be great if we could deliver the right care at the right time that our patients really need instead of shrugging our shoulders and saying, well, the system just isn't set up to meet people's needs that way?

Heather: Yeah.

Mike: So send them to the E.R. or whatever. Whatever resource that we have in the system that we just like that isn't really the right way. But what else do we have?

Heather: That's fantastic. Thanks for joining us in this conversation, Tim. This has been so much fun. Really fantastic way to learn a little bit more and kind of talk about the issues at hand.

Tim: Well, you're most welcome. It's a pleasure for me to get to participate with BACON. I'm a regular listener to the podcast and admire the work that you guys do.

Mike: Thanks, Tim. We appreciate it.

Mike: So thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, And if you have questions, comments or suggestions, we'd love to hear from you. Please email us at That's

Heather: BACON is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. See you next time.

Mike: See you next time.