Alan Roga, MD, FACEP

As revenues recover, it's clear that many hospitals are still grappling with rising costs. However, the hospitals that stand out are those embracing technology to drive efficiency and operational improvements, significantly reducing staff burnout. 🌟 Healthcare professionals entered this great profession to care for patients, not to be bogged down with manual tasks. That's why leading hospital systems are implementing comprehensive applications to enhance people, processes, and automation. This approach ensures cost-effective, top-of-license performance, ultimately benefiting both staff and patients. 💼❤️💡🔧 #GetReady #HealthcareInnovation #TechInHealthcare #OperationalExcellence #PatientCare

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If you click on the link you will see a report called Expense Distribution. I know this report more than you can imagine. It's based on paid claims. It shows that for this plan half the members were essentially self-insured as individuals. If I was the CEO of this company, you can bet I would make sure the rates my employees were paying for their own care were reasonable. If not, I'd be personally liable. #deerhold #ContractRateExplorer #MRFInsights

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🚨 40% of Hospitals Are Losing Money! (Source: Kaufman Hall) 🚨 https://lnkd.in/eEenrkWG While many will shrug and say it is not a big deal because it is the smaller hospitals that are unprofitable, but the reality is much more significant. These hospitals often serve as the largest employers in their communities. When a rural hospital closes, it doesn't just impact healthcare; it devastates local businesses, the broader economy, and the health of that community. Moreover, the presence of a nearby hospital is a critical factor for businesses scouting new locations. Companies know they can't attract top talent if the nearest hospital is in the next county or town. Unfortunately, these hospitals are frequently overlooked by vendors, making it harder for them to thrive. At VantageHealth.ai (and our sister company CompliantHealth.com), we are committed to addressing these challenges. Our value-added solutions aim to move hospitals from red to black through improved revenue streams, reduced costs, increased compliance, and enhanced patient engagement. Let's work together to support these vital institutions and ensure they continue to serve their communities effectively. #Healthcare #RuralHealth #HospitalManagement #CommunityImpact #HealthcareInnovation

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The California Office of Health Care Affordability has recently approved a requirement that all healthcare providers report their annual operating expenses. If those expenses increase more than 3.5% (eventually lowering to 3%) in a year, that provider will be fined, ironically increasing their expenses. The state claims this regulation is aimed at protecting consumers from high healthcare costs. This is the same State of California that recently raised all healthcare workers' minimum wage to $25 per hour (up from $15.50).  For our health system, that results in a $30 million annual cost increase and a 7.5% increase in our salary costs. This is also the same state that passed an unfunded mandate that requires our system to spend about $1 billion to replace a hospital building that they feel is at risk from damage in an earthquake. And it’s also the same state that increased the cap on medical malpractice lawsuits…and has authorized utility companies to raise their rates 15% per year.  So, with all of these unfunded requirements and policies that dramatically increase providers' costs beyond their control, how exactly does the state suggest that we limit our expense growth to 3% per year?  Healthcare cost inflation has already been running at more than 5% before any of these new requirements took effect. Perhaps if California wants to get serious about reducing the cost of healthcare they might look at the managed care plans. The most recent data I could find from the California Health Care Foundation indicates that California managed care companies made $222 billion in 2020. What direct value did these companies provide to the health of our communities? Meanwhile, hospitals and physicians are providing direct patient care and struggling to survive- especially systems like Kaweah Health that serve a high percentage of Medi-Cal (Medicaid) and Medicare patients.  On a side note, the governor did sign a new managed care organization tax into law this year, which was promised to increase Medi-Cal reimbursements to providers, but all signs suggest that he now intends to use those proceeds (nearly $7 billion) to fill holes in his budget's general fund deficit and will not be providing Medi-Cal rate increases. I would humbly suggest that if the state is genuinely concerned about its residents' cost of living, they might look at the state income tax (highest in the country), its gas prices (highest in the country), the essentially unaffordable housing costs, or countless other factors that will have a larger impact on individuals' pockets than beating up healthcare providers with laws that don't make any sense. #hospitals #california #healthcare

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Here's a shocker -- the AHA and the FAH are pushing back against Medicare's mandatory hospital-based bundled payment program. The hospital associations are asking for more time to get ready for a program that will start in 19 months.... It's laughable, of course, but what else should we expect from the agents of the status quo? For those who hadn't kept up, Medicare announced the Transforming Episode Accountability Model several months ago and it's finally going through the end of the rulemaking process. So what's TEAM? A slimmed down version of the Medicare Bundled Payment Model (BPCI and its successor BPCIA) that has been in place for over a decade. There's nothing new about TEAM except that it only covers a handful of inpatient stays and the accountability is reduced to 30 days post discharge instead of 90. Four years ago a dozen or so highly respected leaders in the industry recommended that CMS institute a "DRG+30" across the board. Not just for five DRGs, but all DRGs. And here we are, four years later, and TEAM is set to start in 2026....yes, 2026, not 2025. The first cohort of the original program launched in April 2013, more than 11 years ago. By the time TEAM starts it will have been close to 13 years. Isn't that enough time to get ready Chip Kahn???? All of the published analyses on the Medicare Bundled Payment program showed the same source of savings -- post-acute care. And the savings never negatively impacted outcomes. So it's logical that Medicare makes this mandatory. What's not logical is that it's taken so much time to get to this decision. So let's just get on with it because the taxpayers deserve it and so do Medicare beneficiaries. #TEAM, #BundledPayments, #CMMI

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How'd HCA, Tenet, CHS and UHS do in Q1? Here's a handy little table I put together on high level financial and operating performance in Q1 2024. Net Revenue & Growth: • HCA Healthcare - $17.3B (11.2%) • Tenet Healthcare - $5.4B (6.9%) • UHS - $3.8B (10.8%) • Community Health Systems - $3.1B (1.0%) Adjusted EBITDA & Margin: • HCA - $3.4B (19.3%) vs. $3.2B (20.3%) in Q1 2023 • THC - $1.0B (19.1%) vs. $0.832B (16.6%) in Q1 2023 • UHS - $0.526B (13.7%) vs. $0.421B (12.1%) in Q1 2023 • CHS - $0.378B (12.0%) vs. $0.335B (10.8%) in Q1 2023 Same-Store Admissions Growth: • HCA - 6.2% • THC - 4.2% • UHS - 5.7% • CHS - 3.8% Same-Store Patient Days Growth: • HCA - 5.4% • THC - 3.2% • UHS - 4.4% • CHS - 3.1% Same-Store ER Visits Growth: • HCA - 7.2% • THC - 4.0% Conclusion: Volumes were STRONG in Q1 given effects of calendar and ongoing, sustained elevation in utilization, leading to a favorable setup for most of these operators. Side note: does it bother anyone else that Community Health Systems' logo is CHS, but its stock ticker is CYH? PS - if you like breakdowns like these, join 30k+ others on my newsletter Hospitalogy! https://lnkd.in/gniNmHvz

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What are the biggest changes you are expecting in the next 12 months? We have been speaking with lots of people and have been to many conferences. What we're seeing is a big push to get OP CDI to the front of the line, along with a huge risk adjustment push. We are also being asked, at the highest rate ever, to perform targeted audits of existing hospital coding staff as well. How about you? What changes are you expecting and/or seeing? Would love to start the conversation. #whyisnorwoodeverywhere #changeisgood #changehappens #riskadjustment #opcdi

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Headlines in my feed this morning: (all sarcastic with a hint of truth) -xxxx startup gets lots of millions for (insert fragmented care solution). Venture capital very pleased and still awaiting clinical outcomes. -xxxx decides to exit healthcare after realizing 25% margins are not possible. Patients left without care but it’s fine. Xxxx got a very nice participation trophy. -xxxx AI thingy can replace everyone for 57 cents an hour. Clinicians oppose the solution. Clinical outcomes still pending. AI wrote a very nice press release. -all clinicians everywhere are burned out. If they just worked for agencies they would not be burned out. Burnout is fixed by coaches. Be a coach and use your burnout to unburnout those who are burned out. Only $999/month. Outcomes still pending.

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When is a company sitting on $300 million of cash (with zero debt) valued at only $168 million to investors? In the current moment, perhaps partially because it's a telehealth company. It’s been bad news following bad news for telehealth between the Optum news, Walmart news, and Teladoc Health letting CEO Jason Gorevic go. But among the most fascinating underreported issues around telehealth right now is the fact that Amwell has a negative enterprise value. It appears the other part of the answer is that, unlike Teladoc, investors don’t control the company: co-CEOs Roy Schoenberg and Ido Schoenberg do. Maybe, just maybe, their long term view of telehealth is the right one. Is AmWell undervalued? Had fun looking into this one, and am sure others have a different perspective. https://lnkd.in/eiEJ27Gh

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ASCs see post-procedure payer clawbacks intensify It seems like the payers now have a new trick up their sleeves to continue earning record profits at the expense of the providers. As if the payer's unrelenting efforts to reduce their medical loss ratio and thereby increase profits by engaging "cost containment companies" like Cotiviti, Gainwell Technologies, Optum, Varis, CGI Proper Pay, Performat, etc. These vulture companies are out there earning their commissions, often issuing egregious clinical validation denials and now trying to recover monies paid to providers that were previously authorized by the payer. In my mind, that is unconscionable and borders on unethical behavior. Speaking of clinical validation denials, it amazes me that these CDI and coding individuals working for these auditors are allowed to maintain their credentials. The credentials are intended to represent skill sets and core competencies in coding and clinical documentation improvement, a commitment to maintaining relevance and proficiency in their respective profession. These individuals chose to use their skill sets against providers, where most of these individuals began their careers #trickupthesleeves, #denypaymentafterthefact, #denypaymentafteauthorizing, #egregious, #doianythingforprofts, #overzealousreviwers https://lnkd.in/eRiakXN5

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It strikes me as very important that the court did not rule on geographic restrictions for #340B covered entities. Contract Pharmacy geographic restrictions will: 1. Reduce access for patients 2. Restrict innovation related to patient engagement and access, 3. Likely increase costs to patients, and 4. Create a non-competitive business environment that will likely result in higher dispensing fees. There is no evidence that “remote” pharmacies harm program integrity. More detail on follow on posts on each of these points. Health Resources and Services Administration (HRSAgov), HHS Centers for Medicare & Medicaid Services National Association of Community Health Centers (NACHC) PhRMA #340B #CoveredEntities Advocates for Community Health

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Excellent article by Nona Tepper at Modern Healthcare explaining how Medicare Advantage #starratings are calculated and how they impact member recruitment. While they're not perfect, Stars ratings provide a good quality indicator for those choosing a plan. Check out the article here. Nona Tepper Modern Healthcare

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Here's a question that keeps getting asked, since the FTC banned non-competes, will millions of doctors rush to start private practices if more than 70% of them are currently employed by corporate care organizations? The short answer is no! There is, however, some nuance here since the appetite for starting traditional private practices has completely shifted to the concept of fractional work. Which means it would be more accurate to say that millions of doctors will rush to start fractional private practices due to the flexibility and autonomy provided by this modern model, instead of saying there will be a mass exodus where millions of doctors rush to start private practices that reflect the old, clunky, and expensive traditional models of the past. Using an example from someone I respect, I can show how this is true and done successfully. Paulius Mui, MD is a practicing direct primary care physician as well as the Director of Clinical Information at NextLevel Medical in Houston, Texas. He's also a fractional medical consultant for several digital health startups and runs X-Primary Care, an online think tank that brings together builders, investors, and clinicians who are developing real-time innovative solutions to help make primary care more accessible. For the modern-day physician, this is the essence of entrepreneurship. The flexibility and autonomy offered by this fractional model gives physicians the freedom to explore, while still being able to provide direct patient care services to patients in their community. Using AI, this will be how millions of physicians start and run private practices. So yes, the mass exodus will occur. There just won't be any resemblance to any of the private practices of 20 years ago. ----- Hi, I'm Dr. Mario Amaro, Founder and CEO Ease, and I talk about all things starting, running, and growing a private practice with AI. Follow me, if you are planning to start one or are currently figuring out creative ways to grow one. #PrivatePractice #SelfEmployment #HealthcareOnLinkedin #HeyEase #IndependentTogether #Fintech #Infrastructure #AIinHealthcare #CareDelivery

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The Congressional Budget Office recently released a report on Medicare ACOs. Here's a brief summary mixed with personal comments: ACO types associated with greater savings either a) were led by independent physician groups, b) had a larger proportion of primary care providers or c) had initial baseline spending higher than the regional average. One comment on that last factor I found interesting was that increased expense from post acute care tended to be an area of greater impact: “...postacute care, which includes skilled nursing care and rehabilitation services, is costly and has the potential to be overused or used inefficiently, making it a readily identifiable target for ACOs aiming to decrease spending.” ACOs led by hospitals performed less well because: “If hospitals reduced admissions, then they would earn less revenue to cover their fixed costs, weakening their incentive to generate shared savings.” Something they touched on that I think is a key weakness is that ACO benchmarks are updated over time to reflect the observed spending among that ACO’s attributed beneficiaries. “Because of that structure, ACOs that lower their spending are effectively penalized with lower subsequent benchmarks.” The CBO report also suggested ways to potentially improve the offerings. “Those approaches can be grouped into the following categories: those that would increase providers’ incentives to participate in ACOs, those that would increase providers’ incentives to reduce spending, and those that would increase awareness and engagement of beneficiaries.” One suggestion I called out above is the idea of eliminating “the rebasing of benchmarks using historical spending among an ACO’s beneficiaries and instead use administratively set benchmarks.” I have also found that, due to external impacting factors that occur each year, retrospectively looking at the rate of increase in expenses for the attributed population vs the actual rate of increase for a similar but not attributed population, is a much more fair assessment of the impact of the ACO than a prospectively projected target. Another key issue with ACOs is the lack of patient engagement. It is quite common for patients to a) not know they’re “in” an ACO and b) have no incentives to participate in the ACO’s offerings or services. This article notes “…strategies that rewarded patients for obtaining services from ACO providers could enhance communication and engagement between providers and patients and reduce Medicare spending.” The analysis goes on to say that “Without a clear financial incentive, beneficiaries tend not to obtain care exclusively from ACO providers. One way to strengthen that incentive would be by waiving Part B cost-sharing requirements for beneficiaries who obtain care from their primary care physician or another provider in the ACO.” Full CBO report here: https://lnkd.in/gEUaFZKV

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Busy few months in Healthcare! From Optum closing its Telemedicine Unit, Walmart and Walgreens closing Primary Care Clinics, and Teladoc & Livongo stocks sliding. With all of this, there have been a myriad of comments on where the market is going ranging from Telemedicine is a dying modality and in person care is back, to Primary Care is in trouble. It’s important to realize that the changes that we’ve seen do not all share the same root cause. FIRST, point solutions, which focus only on an isolated part of the patient care journey, which initially received a lot of hype in the US market, have now been shown to have questionable ROI and actually tend to add complexity in the form of “we have an app for that,” which contributes to the plague of care “un-coordination” as well as increased costs and worse patient outcomes. We don’t need a solution that takes care of diabetes. We need a system that takes care of a patient with Diabetes. We don’t need a solution that especializes in taking care of Depression, but yet one that addresses all the needs of a patient with Depression, that may have Diabetes and Hypertension, as well. Therefore, my prediction is that in several years, point solutions will be a thing from the past. SECOND, Walgreens, Walmart and others missed the lesson where Nisha Mehta, MD brilliantly said: “You cannot scale your way out of America’s healthcare problem”. This idea that you can fix all problems from preventive medicine to management of complex diseases with scale is absurd. Why some entities like Oak Street Health and ChenMed are having a relative success when comparing to others that are exiting the market? The answer is clinical work flow! A lot of players have been banking on Medicare advantage for success. Unfortunately, these players entered the Medicare Advantage market with outdated clinical work flows while attempting to serve both a fee per service population and one under value based arrangements, what is nearly impossible to achieve (and scale didn’t help!). They were wrong. I don’t think we need to put into question the future of telemedicine, but yet the future of consumerism. Therefore, No! Telemedicine is not returning to the business as usual of the pre-pandemic era and it’s use in very limited clinical situations. Both telemedicine and remote patient monitoring (the latter to a larger degree) will continue to expand. However, this expansion will likely come from its incorporation into redesigned clinical workflows by traditional players like Hospital Systems and Large physician Groups. That will occur in both low acuity situations like preventive medicine and mental health all the way to management of complex conditions like cancer care and initiatives of Hospital at Home. So, YES! Telemedicine and Remote Patient Monitoring are here to stay, the questions are: (1) In what format? (2) Will patients have a voice in the redesign of this new way of delivering care?

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The future of healthcare interoperability will be focused on agent/s to agent/s data integration, here's why ⤵ 1. On the physician and clinician side, agents will quickly become the primary tool used in clinical practice. These agents will include multiple models that operate seamlessly with one another navigating between tasks to help optimize the care delivery experience. 2. Despite the fact that no one likes portals, especially patients, the idea of the PHR (patient health record) never really took off. In contrast, agents will give patients the freedom to design their own versions of the care delivery stack, not only interacting with their health records and care team, but also with their health plans and families. AI agents are the future in healthcare and we need to build data interoperability to support this future. ------- Hi, I'm Dr. Mario Amaro, Founder and CEO Ease, and I talk about all things starting, running, and growing a private practice with AI. Follow me, if you are planning to start one or are currently figuring out creative ways to grow one. #PrivatePractice #SelfEmployment #HealthcareOnLinkedin #HeyEase #IndependentTogether #Fintech #Infrastructure #AIinHealthcare #CareDelivery

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🚨 Industry Update: More Major Changes in Healthcare Services 🚨 Per Becker's Newsletter today, we are witnessing significant shifts in the healthcare landscape as Walmart Health announces the closure of all 51 health centers and its Walmart Health Virtual Care services. This decision, driven by reimbursement challenges and escalating operating costs, marks a pivotal change in retail healthcare provision. Additionally, UnitedHealthcare and Walmart's co-branded Medicare Advantage plan will be discontinued. In parallel, UnitedHealth Group’s Optum Virtual Care is also closing its doors. Launched in 2021, Optum’s cessation underlines the evolving dynamics and challenges within telehealth services. These closures underscore the need for agility and adaptability in healthcare strategy and execution. At CB3 Connections, LLC, we not only understand these industry shifts deeply but also stand ready to support organizations in navigating these complex changes. Our strategic talent placement and advisory services are designed to equip your leadership to steer through these transformations effectively, providing a sense of reassurance and confidence in these challenging times. #HealthcareIndustry #StrategicChange #Leadership #CB3Connections DM us to learn how we can support your organization's leadership needs in these evolving times.

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ANALYZING PAYER REIMBURSEMENT RATES Ensuring maximum reimbursement is always at the top of a healthcare provider’s mind. But we find too often that many #providers are leaving money on the table with inefficient and infrequent #payer #contract management. CodeToolz is pleased to offer you this Payer Reimbursement Analysis Tool to assist you. Complete this spreadsheet for each of your major health plans. Replace the sample data with your own. You do not need a Box account to access this resource. Here you go: https://lnkd.in/gRxPRB3d

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