Carol DeVol

The Great Reckoning in Medicare Advantage: Collaboration or Division? The landscape of Medicare Advantage is facing its biggest shift in two decades, according to McKinsey, which is presenting new challenges for payers and providers alike. As pressures mount, the vital question emerges: “How can health systems avoid getting the smallest slice of the remaining pie?” In a recent panel of payer and health system executives hosted by Strategy Catalyst, executives from both sectors discussed the future. The consensus? Those positioned to thrive in the impending Medicare Advantage "great reckoning" will be the innovators who foster collaborative efforts to optimize each other's cost structures. What might this entail? • Payers could seek to reduce their own cost-regulating denials and prior authorizations by trying to work collaboratively, focusing on efficient data sharing and solution-driven dialogues with providers. • Providers could streamline contracts to only work with those seeking mutual value, guided by well-defined principles for selecting partners and governing contract performance. Potential collaborative areas: • Jointly deciding on supplemental benefits that will be high impact of the population and promoting their utilization through the health system's medical group. • Establishing joint quality measures that would allow movement to prospective payment systems. • Exploring evidence-based care guidelines that could be agreed upon jointly to reduce administrative burdens, like unnecessary prior authorizations. Join the conversation and let us know your thoughts. For more detailed insights, ask for our two-pager on the future of Medicare Advantage.

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Remember to tune in to Blue Shield of California's webinar on primary care delivery in California today at 12 PM PT. Learn from our CEO, Khanh Gia Nguyen, and other industry leaders on steps being taken to improve primary care service delivery in California and the launch of a value-based payment pilot. Register here: https://lnkd.in/eqwr4RH6 #primarycare #valuebasedcare #healthcareinnovation

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#Policy #Value-based Care California sets health care spending targets joining other States in setting cost targets and States such as Maryland & Vermont who recently applied to the AHEAD model for managing quality and cost across all payers.

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This AEP is expected to be extremely disruptive to all Medicare patients. The Inflation Reduction Act and new CMS Final Rules have caused shockwaves across insurers. MAPD and PDPs are predicted to radically change benefits, premium, patient cost sharing, network participation, and some insurers will pull out of markets or specific counties. It is critical for every senior to assess their existing insurance this AEP and determine the impact on their cost, coverage, and access. You’ll help yourself and staff by referring patients to MedicareOnDemand before and during the AEP for an insurance assessment to ensure a smooth 2025 transition.

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Drex DeFord Advises Simplifying Healthcare for Vendor Risk Reduction: https://lnkd.in/dDvhYsDF First Health Strategic Advisory Board Member & Healthcare Strategist Drex DeFord dives into pressing concerns around the increasingly complex, difficult to manage, and frequently targeted healthcare environment. Drex’s conversations with This Week Health fuel meaningful conversations to spur the change necessary for improving health sector resilience. We’re proud to have such a dedicated member of the healthcare cybersecurity space advising our leaders and ensuring First Health is at the forefront of digital health security innovation. For more insight into First Health’s leadership and board members, visit https://lnkd.in/gQUx5BzD or contact First Health at info@firsthealthadvisory.com. #CISO #CIO #CTO #CDO #Compliance #HIPAA #HealthcareIT #HealthcareSecurity #CyberRisk #ThirdPartyRisk #RiskAssessment #Cybersecurity #HTM #DigitalHealth #PatientSafety

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California's $7 billion healthcare funding reallocation raises concerns about cuts to Medi-Cal coverage. While this move may save the state money in the short-term, lapses in coverage could have long-term negative impacts on patients and providers. In our latest blog, PointCare CEO Everett Lebherz explores the potential consequences of these cuts and offers strategies to navigate these challenges. Follow PointCare to stay informed on how the latest policy changes could impact your clinic. https://bit.ly/3VE09fy

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Direct primary care (#DPC) has made healthcare --> SIMPLE for patients. 🏥✨ The way it should be... S-traightforward 🛣️ Direct Primary Care (DPC) offers a straightforward approach to healthcare. Patients pay a fixed monthly fee directly to their primary care provider, eliminating the complexities of insurance claims, co-pays, and hidden fees. This transparency fosters trust and allows patients to focus on their health without worrying about unexpected costs. I-ndividualized 👤 DPC provides individualized care tailored to each patient’s unique needs. Physicians in DPC practices have more time to spend with each patient, allowing for comprehensive and personalized treatment plans. This individualized attention ensures that patients receive the best possible care for their specific health concerns. M-inimal Bureaucracy 🗂️ By cutting out the middleman, DPC significantly reduces the administrative burden on healthcare providers. This minimal bureaucracy means doctors can spend more time with patients and less time on paperwork. The streamlined process leads to a more efficient and satisfying healthcare experience for both patients and providers. P-reventive Focus 🩺 DPC emphasizes preventive care, aiming to keep patients healthy rather than just treating illnesses as they arise. Regular check-ups, wellness plans, and proactive management of chronic conditions are integral parts of the DPC model. This preventive focus helps patients maintain optimal health and reduces the likelihood of serious health issues in the future. L-ong-term Relationships 🤝 DPC fosters long-term relationships between patients and their primary care physicians. These relationships are built on trust, familiarity, and ongoing communication. A continuous doctor-patient relationship leads to better understanding, improved health outcomes, and a more personalized care experience over time. E-fficient Care ⚡ DPC ensures efficient care by reducing wait times and providing easier access to healthcare services. Patients can typically get same-day or next-day appointments, communicate directly with their doctors via phone or email, and receive timely care when they need it most. This efficiency reduces stress and ensures that patients' health needs are promptly addressed. Thank you all DPC providers for taking the path less travelled. #directprimarycare #directsurgicalcare #directspecialtycare #healthcare

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Aligned, hybrid primary care payment models that combine capitation alongside some fee-for-service payments are gaining traction in California. However, some key decision-makers have questioned the feasibility of adopting capitation as a payment mechanism among self-funded and flex-funded health coverage arrangements. A new issue brief from IHA and the Purchaser Business Group on Health (PBGH) 's California Quality Collaborative explores how regulatory oversight of health coverage affects opportunities for hybrid primary care payment in self-funded health insurance arrangements in California. The brief examines several topics, including: ✔️Primary care payment alignment and the role of capitation ✔️Regulatory context related to primary care payment in California ✔️Primary care capitation in self-insured plans: allowable conditions, remaining uncertainty Access the full brief here: https://hubs.li/Q02yr2770

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Medicare Advantage plans should be key to improving patient care while also bending the nation's health cost-curve. Hard to read today's The Wall Street Journal Christopher Weaver Tom McGinty Anna Wilde Mathews Mark Maremont story highlighting how MAPD plans sought higher Medicare payments to provide less or no beneficiary care. "Insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated generated $8.7 billion in 2021 payments." Startling to read examples such as patients diagnosed with HIV either did not have the disease or were not being properly treated despite plans receiving higher payments. "Less than 17% of patients with insurer-driven HIV diagnoses were on antiretroviral drugs." Also depressing is the news that plans are charging beneficiaries high out-of-pocket costs for prescribed treatments and then still seeking higher payments from Medicare in subsequent years after the patient has been successfully treated. "Insurers subsequently told Medicare that more than half of the patients who had received the drug treatment still had hepatitis C in a future year, leading to millions of dollars in extra payments." Read the full story here: https://lnkd.in/e6mXrN8R

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Gozio Health announced record growth in the first half of 2024.The company welcomed health system partners including UW Health, Emory Healthcare and OSF Healthcare in the first quarter alone amid growing demand for mobile engagement solutions that improve patient experience. Following a pivotal year of healthcare mergers and acquisitions, health system executives are prioritizing strategies that improve patient access, such as wayfinding, scheduling and registration. Consumer expectations for healthcare mobile experiences are high, according to a 2024 Gozio-commissioned patient survey, with 89% of respondents saying they want to manage their healthcare through a single platform. However, most patients have to access multiple platforms to manage their healthcare, which results in a frustrating experience. “We knew that our mobile digital front door strategy was lacking. While OSF had a solid digital front door strategy via our website, with a great team supporting it, we wanted to do more to meet patients where they are across multiple channels," said Melissa Shipp, vice president of digital experience, OSF Healthcare, one of Gozio's newest clients. #patientexperience #patientengagement #digitalfrontdoor https://lnkd.in/geWu4AWk

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Good news! The issue with PY2023 Provisional Settlement shared savings payments has been resolved, and all payments have been distributed. Check your IPC Portal for details. If you need guidance on the next steps, Kona Medical Consulting is ready to assist. #HealthcareFinance #ACO #KonaMedicalConsulting

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#PartD plan sponsors are increasingly placing #genericdrugs on higher formulary tiers. To evaluate this trend and specific policies' impacts on #patient costs, Avalere analyzed longitudinal changes in generic tier placement, patient out-of-pocket spending, and negotiated pricing within #Medicare Part D. Read our findings here: https://lnkd.in/eFaGbaXm

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Medicare & #Medicaid Services (CMS) is currently executing a strategy to claw back what it claims were overpayments prior to the 2021 Patient-Driven Groupings Model, and many agencies are struggling with Medicare Advantage (MA) contracts that impose significant prior authorization requirements and reimburse at around 25% below traditional Medicare. We believe there is still a good investment opportunity in hospice, which has fared better than home health in recent CMS fee schedules, and particularly in palliative care, which is increasingly seen as an important component of VBC.

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In a new article for InsuranceNewsNet, Susan Rupe sheds light on alarming insights from Jared Landis, vice president of research at Advisory Board, on how the healthcare industry is failing patients -- and how new health plan models could be the answer. At PeopleOne Health, we couldn't agree more. That's why we're passionate about our innovative model that removes barriers and provides members with high quality care. Check out the full article here: https://bit.ly/3WUP2QC #HealthInsurance #HealthcareTrends #PatientCare #HealthcareInnovation

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