Brandon K. Sim

To meet CMS’ commitment to have all #Medicare beneficiaries in value-based payments (VBP) by 2030, payers have to dig deeper into #VBP design flaws and explore new strategies like: •Creating a coordinated set of VBP model designs to cut wasteful or inefficient spending without asking one participant to forgo all the revenue. •Introducing real savings requirements for shared savings, or implementing a risk-score growth cap to encourage better care practices. •Leaning into mandatory participation in new VBP programs to help ALL types of Medicare beneficiaries – not just larger-scale organizations. Read more about how these solutions can help accelerate VBP adoption in a recent Health Affairs article I wrote with Amol S Navathe and Daniel Shenfeld (linked in comments) #HealthcareonLinkedIn

21

2 Comments

Payers are increasingly turning to advanced actuarial models to enhance their decision-making processes and optimize patient outcomes. By integrating consumer data into these models, we're not just predicting costs; we're reshaping how healthcare is delivered and financed. Here are some key use cases where advanced actuarial modeling stands out: 1. **Personalized Premium Setting**: Leveraging consumer behavior data allows for more accurate and individualized premium calculations. By analyzing lifestyle choices, purchasing behaviors, and wellness activities, payers can tailor premiums that reflect the true risk and potential healthcare costs of individuals. 2. **Enhanced Risk Assessment**: Consumer data provides deeper insights into the social determinants of health, offering a broader perspective on risk factors. Actuarial models that incorporate this data can better predict high-cost events, leading to more effective risk management strategies. 3. **Targeted Health Interventions**: With a richer dataset, models can identify at-risk populations and guide the deployment of targeted intervention programs. This proactive approach not only improves patient health but also reduces unnecessary expenditures by preventing adverse health events before they occur. 4. **Improved Member Engagement**: Understanding consumer preferences and behaviors helps payers design more engaging and effective communication strategies. This results in higher member satisfaction and retention rates, as interventions and communications are more likely to resonate and encourage positive health behaviors. 5. **Fraud Detection and Prevention**: Advanced modeling techniques can detect anomalies in claims data that may indicate fraudulent activities. By integrating consumer data, these models become more adept at spotting irregular patterns, safeguarding against losses and ensuring financial stability. The integration of consumer data into actuarial models is not without challenges, particularly around data privacy and security. However, with robust data governance frameworks, we can harness the full potential of this data while upholding the highest standards of consumer protection. Let's connect and discuss how we can further advance the role of actuarial science in healthcare. The future is data-driven, and together, we can lead the way. #ActuarialScience #HealthcareData #DataAnalytics #HealthcareInnovation #ConsumerData

10

🚨New #JAMA Viewpoint 🚨 “Misaligned Pharmacy Incentives in Value-Based Care” The authors discuss how rising #prescription drug spending has been particularly challenging in the context of value-based contracts between payers and providers. This is partly due to confidential #rebates, which create misaligned incentives between payers/PBMs and hospital administrators. Read more below: 🔗 https://lnkd.in/dwzBT4WD #marketaccess #pbm #access #pricing #payer #valuebased #valuebasedcare #patientjourney #patientaccess #pharmacy #managedcare #pharma

10

A thoughtful piece from The Wall Street Journal on a level of misdiagnosis to enhance the profits of payors in Medicare Advantage. For me, this article shines a light on a risk of AI and AI copilots in care, in functions including diagnosis to coding and billing. If the training data leads the utilized AI to maximize profit as a (not just the) driver, unintended margin not mission outcomes will win. Don't get me wrong, I believe in a relatively informed way that AI is the solution for our healthcare system. AI can solve for fraud, waste and abuse; it can produce more efficacious drugs and devices faster; it can enable clinicians to be even more accurate and maximize the time they can spend with patients (and in turn make the system overall more effective and profitable). But, as we race to implement, we must be mindful of the risk of training with less than absolutely perfect data sets. No luddite here, but mindful of the consequences. https://lnkd.in/gG-Hy_GK

20

AccendoWave - A Pain #Data Company More recently, the federal government has begun using the QIS program and QRS parameters to advance health equity. Federal rules now require all marketplace insurers to adopt a strategy for reducing health disparities and to stratify certain clinical data by race and ethnicity. While state-based marketplaces (SBMs) have authority to supplement these federal minimum QIS and QRS standards with state-specific quality rules, most have hewed closely to the federal default approach. California and Washington are notable exceptions. Each has implemented a customized QIS program and robust data collection standards to identify and reduce racial and ethnic health disparities. Time to Focus on - #Pain not being Believed. A Root Cause Health Equity Problem. A Top 4 Global Health Equity Solution and Top 15 Global Remote Monitoring Company, AccendoWave, benchmarks objective brain wave pain data (specialty, gender, age) and has nine #pain databases: Emergency Department, Maternal Health, Oncology, MSK, Medical Surgical, ICU, #Women, Adults, #Seniors to eliminate bias, improve outcomes and reduce health care costs. If desired, AccendoWave can also create customized pain databases for partners that can be accessed on the Datavant platform.

5

Manatt, Phelps & Phillips, LLP's take got me: "CMS is recognizing the role of digitally enabled care in improving access and outcomes." They also propose these new models "present health tech companies with opportunities to target new markets" because of the new/extra funding—such as viewing state Medicaid offices as new partner opportunities, which I've been seeing a lot of talk about recently in my feed. What do you think? I guess being in New Mexico, where almost half of our state is covered by Medicaid, Medicaid and MCOs have been a primary strategic partner/target market for 15+ years, and a somewhat omnipotent source driving most investment and initiatives. ------------------ More about the models: The Transforming Maternal Health (TMaH) model will issue agreements to up to 15 state Medicaid agencies to develop and implement a whole-person approach to pregnancy, childbirth, and postpartum care. The Innovation in Behavioral Health (IBH) model will develop and implement state-administered approaches which integrate behavioral, physical, and social supports to coordinate and manage care for Medicare and Medicaid beneficiaries with moderate-to-severe mental health conditions or substance-use disorders (SUD). I thought to myself, "wait, aren't we already doing that?" But they clarified: through the new models, CMS is encouraging states and providers to invest in technology and supporting infrastructure. ------------------ 🎉 What I'm excited about: Continued support for entities to get connected and the continued case for HIEs to expand their capabilities. Specifically, EHRs, HIEs, and remote patient monitoring (RPM). AND.... 🎉 "Additionally, CMS will support states with implementing data infrastructure to enable collection of Health-Related Social Needs (HRSN) data and referral to support resources." ------------------ 🤯 What I didn't realize: "It is estimated that only 6% of behavioral health facilities and 29% of substance use disorder treatment centers in the U.S. utilize EHRs, whereas nearly 4 in 5 office-based physicians (78%) leverage an EHR platform today 🤯 I'm having a hard time following along with all the new models coming out of CMMI, though 😉 Interesting piece all around, good info.

3

VERY frustrating healthcare insurance cost forecast from JP Morgan! Yet complicated authorizations, time consuming denials on standard of care and growing unworthy appeals are abundant in the offices of providers and Hospitals. Please check out this report that discussed the expected costs and continued rise in insurance premium costs despite record breaking profits for the commercial insurance industry. 1. UnitedHealth Group: $22.4 billion Total net earnings in 2023 were $22.4 billion, up 11.2% year over year. UnitedHealthcare's total earnings from operations in 2023 were $16.4 billion, up 14.2% year over year. 2. CVS Health: $8.3 billion Total net income in 2023 was $8.3 billion, up from $4.3 billion in 2022. Aetna reported nearly $5.6 billion in adjusted operating income for 2023. 3. Elevance Health: $6 billion Total net income in 2023 was nearly $6 billion, up 1.6%. The insurance division reported a total operating gain of $6.9 billion in 2023, up 14.4%. 4. Cigna Group: $5.2 billion Total net income in 2023 was nearly $5.2 billion, down 23% year over year. The insurance side of the business, Cigna Healthcare, reported an operating income of $4.2 billion in 2023. 5. Centene: $2.7 billion Total net income in 2023 was $2.7 billion, up 124% year over year. In the fourth quarter, net income was $45 million, compared to a loss of $219 million year over year. 6. Humana: $2.5 billion Total net income totaled nearly $2.5 billion in 2023, down 11.3%. The company's insurance segment reported an operating income of $2.7 billion in 2023. #physicians #hospitals #healthcare #insurers https://lnkd.in/gst6CS9y https://lnkd.in/g6su6SuJ

2

Healthcare technology is in trouble. After the relative boom time we experienced through during the pandemic, the fervor to innovate in health systems and payers seems to have dried up. While organizations continue to post stellar earnings, they also continue to lay off experienced health technology people en masse. Why? I think it's time for a bit of honest reflection. 70% of all enterprise healthcare technology projects fail. 17% of of all large scale IT projects go so badly that they threaten the very existence of the company itself. Bridging Business & IT, LLC For projects with a total price tag of over $1MM, that failure rate jumps to over 90%. And the ever prescient Clayton Christensen believed that the failure rate for all new product introductions is 95%. This is not new information. What is new is the most recent E&Y Pulse Survey that has health system CIOs believing that 7 in 10 of their healthcare IT projects have had no discernible #ROI. None. And this is for the projects that didn't fail. https://lnkd.in/gRgVt_Xs This is an existential crisis that health technology must face honestly and soberly. Lack of planning and poor communication are the core culprits. Clunky and outdated Waterfall project methodologies can be blamed for many of these failures. And frankly Agile disciples could use a bit more planning before they start iterating so they know what they're building. There are, however, some problem actors and business models that need to be called out. The historically biggest culprits, in my humble opinion, are large, institutional, enterprise software vendors and their server-based architectures. For decades they feasted on seven figure licensing deals, sometimes humble-bragging to potential implementation partners about 5:1 or 7:1 implementation cost to license cost ratios. Companies just went along with it, because no one gets fired for buying IBM, right? But the failures in this segment are legendary. And many have indeed been a key cause in the parent company failure. As for the ROI, there was a bright spot in the E&Y Pulse Survey. Despite not having established a demonstrable ROI, 96% of them still wanted to move forward with the projects, believed the investment was worth it. So the issue isn't necessarily that the projects aren't generating value, the issue is that the organizations (and their vendors) didn't do a good job up front validating agreed upon ROI metrics and measures. They don’t fully understand the value it is (or isn't) creating. This is our collective job to be better at this. So what can we do to reduce the failure rate and get health systems and payers back into investing in #innovation? #ROI #startups #valueengineering #goldenpath #LCNC #opensource

30

5 Comments

The 'payvider' becoming a healthcare delivery niche player. It appears all outpatient...infusion, pharma, home health, urgent care, etc. Seeing more signs of consumers being directed by payers. No real, big box hospital purchases. Are beds being isolated and commoditized? #hospitals #healthcare #business #payers

4

4 Comments

Baffled by the healthcare system? Join Michael Navin & myself for an amazing #podcast #onlyhealthcare Listen on nearly all platforms for our new regular discussion series hitting #transparency and more!

3

Health insurers' affordable housing investments reached a significant milestone in 2024, with major players committing billions to improving health outcomes. Here’s a quick overview + key insights based on my latest article and discussions with industry experts. Much of the industry's housing development and support services are now standard. However, there’s continuous investment in innovative strategies to maximize health benefits and cost savings. How are insurers differentiating their housing investments?👇 - Strategic partnerships & community involvement - Integration of health and social services - Focus on health equity and vulnerable populations - Leveraging data and technology to track outcomes Specific players to highlight: 1. UnitedHealth Group: Surpassed $1 billion in investments, creating 25,000 homes across 31 states. Their Health & Housing Fund partners with key organizations to provide comprehensive services to residents. 2. CVS Health: With Aetna’s help, they’ve invested over $1 billion, including $35 million in Hawai’i recently, supporting 12,600 families. 3. Centene Corporation: Partnered with McCormack Baron Salazar to build communities in eight states, investing $900 million in loans for direct construction. 4. Kaiser Permanente: Committed $400 million to create or preserve 30,000 affordable housing units by 2030. 5. Elevance Health: Formerly Anthem, has invested $410 million as of 2021. Key trends to watch: - The impact of these investments on health outcomes and healthcare costs. - The role of non-profit hospitals in similar investments. - The evolution of partnerships and integration of services within housing projects. - The long-term sustainability and scalability of these investments. Insurers recognize the significant health benefits and cost savings from investing in stable, affordable housing. The private sector’s involvement in addressing social determinants of health is crucial for reducing disparities and improving community health. Time will tell, but for now, I’m closely watching the impact of these housing investments on health outcomes. If you enjoyed this post, subscribe to my newsletter, Healthcare Huddle, for twice-per-week insights into healthcare industry trends and analysis👇 [https://lnkd.in/e4ZgTwwx]

3

🎙️ On the latest episode of The Healthcare Landscape podcast, I had the privilege of sitting down with Jaswinder D. (Jessy), CEO and chief architect of Care.io, a pioneering platform for healthcare data governance, interoperability, and innovation. During our riveting conversation, Jessy pulled back the curtain on the staggering data challenges facing independent medical practices and how inefficient data management is hindering care quality, operational efficiency, and the ability to leverage cutting-edge technologies like AI and machine learning. #HealthcareData #DataGovernance #Interoperability But it's not all doom and gloom! We explored groundbreaking solutions for: Aggregating disparate data sources into a unified, standardized repository #DataAggregation Simplifying data exchange and collaboration while ensuring privacy/compliance #DataSharing #DataPrivacy Extracting powerful insights from your own clinical data assets #DataAnalytics #ValueBasedCare Laying the governance foundation for responsible AI/ML adoption #ArtificialIntelligence #MachineLearning Jessy shared eye-opening insights, real-world examples, and a vision for how optimized data strategies can revolutionize value-based care models, personalized medicine, and the overall patient experience. #HealthcareInnovation #DigitalHealth #HealthcarePodcast #HealthIT If you're an independent provider, practice administrator, or healthcare IT professional feeling overwhelmed by the data deluge, this is a can't-miss listen => Health data governance & use

19

3 Comments

Many thoughts as Medicare Advantage continues to come under scrutiny. - MA has features of a value-based program, but most of the current "value" is being delivered through diagnosis capture and complexity payments. Ironically, much like FFS, it pays more to keep people sick (or make them look sick). Don't think that's anyone's definition of value. - To be fair, most doctors (especially specialists) don't do a great job of capturing diagnosis and patient complexity beyond their immediate area of expertise. (We're especially bad at this in MSK). We should have accurate representation of a patient's health in the medical record. Complexity and co-morbidities affect treatments and outcomes. We don't yet have a good way to account for this complexity -- and it's becoming clear the MA system isn't it. - EMRs make all of this worse. It's both too easy and too hard to record, change, or resolve diagnoses. EMRs should facilitate accurate complexity capture and treatment personalization. The goal shouldn't be to increase billing, it should be to increase sophistication and precision. - As MA scrutiny grows, the business model of many alternative care models (especially in primary care) will be challenged (potentially dealing another blow to retail healthcare). - CVS' purchase of Signify health is put into full context by this article. - It boggles the mind that CMS can develop and administer a program that nets billions for inscos (at the expense of taxpayers) while reducing physician reimbursement yearly and rolling out ineffective VBC programs for providers. CMMI should have an open-door policy for anyone delivering care and working on true value-based models. Ears, eyes, and minds should be wide open. h/t Mahek Shah MD, MBA Moby Parsons, MD #medicine #healthcare #vbc #valuebasedcare #health

25

11 Comments

Upgrades happening through AI A recent study by Mount Sinai has unveiled that real-time AI alerts can reduce patient deaths by a staggering 43%. 🏥✨ This isn't just a statistic; it's a monumental leap towards enhancing patient care and saving lives. The most interesting for me, is that the system currently used at most hospitals, the Modified Early Warning Score (MEWS), used to help determine if a patient's health is deteriorating, can now potentially be modified to leverage more than the 5-6 parameters it's being using to determine a score. This scoring system was published in 1997 and very little modification or variations have been added to this scoring scale...until now. study can be found here: https://lnkd.in/gq8pUszA #AIhealthtech #clinicalanalytics #mews

15

Now that the health plans have all submitted their Medicare Advantage bids for the 2025 calendar year, I thought it would be worth bringing up a recognized problem in the CMS Benchmark calculation (United States Per Capita Cost or USPCC) that falsely lowers the benchmark. If you aren’t familiar with how these benchmarks are calculated, I wrote a simplified explanation last month which you can find here: https://lnkd.in/gSmvq9mB The first step in calculating this benchmark is for CMS to add up the risk-adjusted monthly total fee-for-service spend for all Traditional Medicare beneficiaries and get an average spend per beneficiary per month. The thing is, they include beneficiaries that only have Part A (institutional expenses) but not Part B (professional expenses) as well as those that only have Part B and not Part A. Obviously, that means they’re counting people where a meaningful portion of their medical expenditures are not included as if they’re the same as people where all of their spend is included. In effect, this lowers the average monthly cost per beneficiary. Yet, this is the benchmark that is used to represent the cost to manage the combination of all Part A and Part B expenses for a population. That is, the MA bids have to cover both Parts A and B for their whole population but it is being compared to a benchmark where some of the people only have one or the other. Even MedPAC has recognized this issue and calculated in 2017 that if they were to only include beneficiaries with both Parts A and B, it would raise the benchmarks by about 1%. This fact tends to be ignored in the news articles decrying the higher spending in MA when compared to Traditional Medicare. #MA #MedicareAdvantage #Benchmarks #ManagedCare #Medicare

31

2 Comments

Real-world evidence is a powerful tool for payers, offering insights beyond raw data. This is largely because RWE is gleaned by analyzing real-world data, such as healthcare utilization patterns and treatment outcomes, etc. By leveraging RWE, payers can identify areas for cost reduction and develop targeted interventions, ultimately ensuring access to the most effective treatments for patients in various real-world scenarios. Beyond financial optimization, effective use of RWE improves patient outcomes—truly a win-win for everyone. #RealWorldData #RWD #RealWorldEvidence #RWE #Healthcare

2