Gregory Busch, DO, MS, MBA

An Outpatient Clinical Documentation Improvement (CDI) program offers substantial advantages to healthcare organizations by elevating patient care and operational efficiency. By integrating risk stratification with chronic conditions, enhancing quality measures, addressing social determinants of health, and establishing a collaborative team empowered by technology, such strategic initiatives result in improved patient outcomes and streamlined operations.

3

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

26

11 Comments

Key Strategic Insights = A Successful OP CDI Program The challenge of value-based care starts with a collaborative approach, when launching an Outpatient Clinical Documentation Integrity (OP CDI) program. Here are some key strategic insights to success: 1. Engage with Population Health Understand Pain Points: Begin by understanding the specific challenges faced. This fosters collaboration. Tailored Questions: Use customized questions to facilitate productive discussions and ensure alignment with needs. 2. Effective Software Implementation Manage Patient (Pt.) Volumes: Implement software solutions to efficiently handle pt. volumes. OP CDI Calculator: Utilize a calculator to determine Full-Time Equivalent (FTE) needs. Data Analytics and Reporting: Emphasize the importance of continuous improvement via data analytics. 3. Workflow Creation Establish Robust Workflows: Create strong workflows before integrating reviewers. 4. Collaboration & Communication Promote Strong Collaboration: Encourage robust communication between key stakeholders. Leverage Software: Use technology to reduce physician burnout & streamline communication. 5. Patient-Centered Approach Address social determinants of health (SDOH) & ensure accurate documentation of conditions and care plans. Patient Outcomes: Keep patient care at the center of all doc. & workflow processes. 6. Regulatory Compliance Adhere to Guidelines: Follow regulatory requirements such as CMS guidelines on Hierarchical Condition Categories (HCC) coding to avoid penalties and enhance credibility. 7. Measurable Outcomes Set Clear Goals: Aim for measurable outcomes like improved HCC recapture rates, enhanced RAF scores, better HEDIS measures, and addressing SDOH needs. 8. Stakeholder Engagement Involve All Stakeholders: Ensure that executives, clinicians, and other relevant parties are involved in planning and implementation process. Success Stories Recently, I helped several CDI directors validate their cases for OP CDI programs within Accountable Care Organizations (ACOs). By engaging with population health leadership, we identified key issues such as RAF gaps and HEDIS measures, and tailored processes to address them. For instance, a CDI director I guided successfully identified HCC and HEDIS recapture as their biggest pain points. With strategic solutions in place, they are now ready to implement the project for the 2025 budget yr., aiming to improve their HCC recapture rate by 20%, leveraging data analytics for outcomes and improvement needs. Benefits of Implementing These Strategies Align Risk Stratification: Properly align risk stratification with chronic conditions and healthcare needs. Quality Measures: Improve quality measures and address SDOH. Collaborative Team: Ensure success with a collaborative team supported by technology. Overall, these strategic actions will enhance patient care and operational efficiency. #Healthcare #Leadership #CDI #PatientCare #ValueBasedCare #HealthcareInnovation

21

9 Comments

MA: The "STAR" of the show. Silly me, given my recent articles on benchmarking and bidding in Medicare Advantage (MA) as well as the recent stargate fiasco that is happening this year, I thought I’d write a brief article that explains the basics around the star ratings. Well, just like those other topics, the details are super complicated and confusing. 2024 Star Ratings represent services provided in 2022, but don’t impact payments until 2025 and the technical notes include words and phrases like “clustering,” “relative distribution” and “Tukey outer fence outlier deletion.” So instead of a superficial overview, I am making the mistake of taking a deep dive into Star Ratings. I apologize in advance for pulling you down this rabbit hole with me. Given the extent of the information, I’m choosing to start off by sharing it in bite sized pieces and will then post the whole thing in its entirety once I’m finished. Let's start off with...Why do we even have Star Ratings? As you know, in Medicare Advantage, private health plans are paid a fixed monthly amount for each of the Medicare beneficiaries that are signed up with their plan. Given the number of options an individual beneficiary may have to choose from, CMS wanted to help them choose the best plan for them and not just incentivize plans to provide high quality care, but to facilitate growth in the best performers. At a high level, the Star Rating system has two impacts: a guide to consumers choosing among MA plans and as a factor in determining MA plan payments. It is important to remember that there is no real quality data for Traditional Medicare, so star ratings only enable comparisons between MA plans and not between MA and Traditional FFS Medicare. #MA #Medicare #Stars #Tukey

27

2 Comments

CMS Proposes 2.8% Cut to Medicare Physician Fees for 2025 — One group calls the proposal "critically short-sighted" This summarizes the dire situation of CMS proposed reduction in the yearly decrease in physician payment when all physician practices are experiencing inflationary pressure and increasing expenses year after year. Patients potentially suffer with more and more physician practices limiting the number of Medicare patients in their practice. I see practices indirectly limiting Medicare patients by offering early morning appointments like 7 AM or 5 PM, knowing these patients do not do early appointments, knowing firsthand when I notice scheduling specialist visits for a family elderly parent that these were the times offered or providing a time months out. Here is for Congress to pass the Strengthening Medicare for Patients and Providers Act to implement an annual inflation-based physician payment update tied to the Medicare Economic Index, and modernize Medicare’s antiquated budget neutrality policies by enacting the Provider Reimbursement Stability Act. "A 2.8% reduction to the conversion factor would be alarming in the best circumstances, but to propose doing so at a time when 92% of medical groups report increased operating costs and are otherwise struggling to remain financially viable is critically short-sighted," Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association, said in a statement "Medicare physician reimbursement is on a dire trajectory and these ongoing cuts continue to undermine the ability of medical practices to keep their doors open and function effectively -- the need for comprehensive reform is paramount." #paymentreduction, #paymentdecrease, #physiciansworkingforless, #inflatioanrypressure, #diretrajectory https://lnkd.in/eVkGHBeM

32

4 Comments

I’m thankful that I could share my thoughts at that very hearing. There is so much misinformation about 340B. For me, it comes down to two main points: 1- if hospitals need that money as a subsidy to fund everyday activities, they should just ask for a subsidy. Let’s open up the books of these institutions, which already get a huge subsidy with their non-profit status, and see why they are running in the red. Are they really losing money on Medicaid patients or are they just bloated and inefficient? 2- let the subsidy follow the patient. This is a drug benefit program. Why does the funding go to an institution? Imagine if we did that with SNAP, giving a bunch of money to large restaurant chains in exchange for their promise to use the revenue to provide food for poor people (with no oversight to ensure that’s done). We don’t do that; instead we give the benefit to the person who needs it. Let’s change 340B to match that model. Adam J. Bruggeman, MD, MHA, FAAOS, FAOA Daniel Choi Colin Yokanovich John Strom Peter Stein Adam Fein Deborah Williams Lisa Grabert Maya Babu, MD, MBA Katie Orrico Larry Bucshon, M.D. Ann M. Richardson, MBA

23

1 Comment

Speak Up! Comments due by July 1st on the draft CMS guidance related to Maximum Fair Price (MFP) and its interaction with 340B. There is a huge flaw... nay, intentional and misguided policy that is clearly the result of powerful lobbying efforts by those that profit from the 340B racket. CMS is requiring that covered entities dispensing drugs subject to the MFP voluntary report 340B claims. This approach is fundamentally inadequate, not only undermining the effectiveness of drug pricing reforms but also inviting exploitation. The voluntary nature of this system allows covered entities, such as hospitals, to potentially manipulate the pricing benefits to their advantage. Since there is no compulsory mechanism to report whether a drug sold at a discount is under the 340B or MFP, these entities can feasibly claim discounts under both programs for the same drug—without sufficient checks. This loophole is not just a gap; it's a wide-open door for financial misuse, allowing covered entities to "double-dip" at the expense of patients, manufacturers and, ultimately, the taxpayers. And you know that I am no apologist for pharma. But in this case, the manufacturers seem to have had the less effective lobby, as they are put in a rather precarious position. Without a reliable way to verify the eligibility of sales under 340B and MFP, they are at a heightened risk of financial losses and increased regulatory complexity. The lack of mandatory reporting leads to a non-transparent system where accountability is all but absent. Transparency and accountability must be non-negotiable elements of our healthcare system; yet they continue to be put on the chopping block and up for bid to the highest political spender or most influential lobby.

32

5 Comments

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

19

2 Comments

𝐓𝐡𝐞 𝐑𝐨𝐥𝐞 𝐨𝐟 𝐄𝐑 𝐍𝐮𝐫𝐬𝐞𝐬 𝐢𝐧 𝐄𝐦𝐞𝐫𝐠𝐞𝐧𝐜𝐲 𝐌𝐞𝐝𝐢𝐜𝐢𝐧𝐞 Emergency Room (ER) nurses play a pivotal role in the fast-paced and high-stakes world of emergency medicine. As a recruiter specializing in healthcare professionals, I recognize the unique skills and attributes required for success in this critical field. 1. 𝐐𝐮𝐢𝐜𝐤 𝐃𝐞𝐜𝐢𝐬𝐢𝐨𝐧-𝐌𝐚𝐤𝐢𝐧𝐠: ER nurses must make swift, informed decisions to stabilize patients and prioritize care. This demands a keen ability to assess situations rapidly and take appropriate action in high-pressure environments. 2. 𝐀𝐝𝐚𝐩𝐭𝐚𝐛𝐢𝐥𝐢𝐭𝐲 𝐚𝐧𝐝 𝐅𝐥𝐞𝐱𝐢𝐛𝐢𝐥𝐢𝐭𝐲: The ER is unpredictable, with varying patient needs and emergencies. ER nurses must be highly adaptable, able to pivot quickly between different tasks and patient conditions without compromising care quality. 3. 𝐒𝐭𝐫𝐨𝐧𝐠 𝐂𝐥𝐢𝐧𝐢𝐜𝐚𝐥 𝐒𝐤𝐢𝐥𝐥𝐬: ER nurses need a broad range of clinical skills to handle diverse medical situations. From trauma care to cardiac emergencies, they must be proficient in various procedures and equipped to manage complex cases efficiently. 4. 𝐄𝐟𝐟𝐞𝐜𝐭𝐢𝐯𝐞 𝐂𝐨𝐦𝐦𝐮𝐧𝐢𝐜𝐚𝐭𝐢𝐨𝐧: Clear communication is essential in the ER. Nurses must convey critical information quickly and accurately to physicians, patients, and families, ensuring everyone is informed and coordinated during emergencies. 5. 𝐄𝐦𝐨𝐭𝐢𝐨𝐧𝐚𝐥 𝐑𝐞𝐬𝐢𝐥𝐢𝐞𝐧𝐜𝐞: The ER environment can be emotionally intense. ER nurses must possess strong emotional resilience to cope with stressful situations, providing calm and compassionate care to patients in crisis. 6. 𝐓𝐞𝐚𝐦 𝐂𝐨𝐥𝐥𝐚𝐛𝐨𝐫𝐚𝐭𝐢𝐨𝐧: ER nurses work closely with a multidisciplinary team, including doctors, paramedics, and support staff. Strong teamwork skills are crucial for delivering coordinated and effective emergency care. 7. 𝐏𝐚𝐭𝐢𝐞𝐧𝐭 𝐀𝐝𝐯𝐨𝐜𝐚𝐜𝐲: ER nurses are advocates for their patients, ensuring they receive timely and appropriate care. This involves monitoring patient conditions, communicating needs to the medical team, and providing support and reassurance to patients and their families. ________________________________ If you're looking to hire skilled ER nurses who can excel in the demanding field of emergency medicine, let's connect. Together, we can find the right candidates who bring the expertise, resilience, and dedication needed to thrive in the ER. 👉 Let's Talk 👈 📞 Work Cell: (740) 267-4656 📨 Email: zach@medforcetalentsolutions.com #HealthcareRecruitment #EmergencyMedicine #ERNurses #MedForceTalentSolutions

14

Why do UnitedHealth's #MedicareAdvantage patients have a 15x higher rate of diabetic cataract diagnoses versus the general population? Hint: the vast majority of them don't actually have diabetes. Some don't even have cataracts. But each one of these diagnoses adds $2863 to the insurer's bottom line each year. This WSJ article uncovered a similar story for HIV, AFib, and Parkinson's, across many MA plans (not just from United). CMS administrators won't admit this in public, but Medicare Advantage's risk adjustment formula is basically a license to steal. CMS shouldn't be paying for things that it can't effectively police. #ethicalhealthcare #hippocraticcapitalism #healthcarefraud

2

CVS Health's CFO made a striking confession: "The goal next year is margin over membership". He then explicitly acknowledged the potential loss of up to 10% of their Medicare members to bolster financial margins. What does this mean? In plain terms, one of America's largest healthcare giants, with projected annual revenues nearing $360 billion (still 10% more than last year), is considering reducing its patient base—yes, **patients** (aka members)—under its #MedicareAdvantage plans. This decision comes as a result of growing "utilization pressures"- a payer euphemism indicating that more people are seeking the care they desperately need. And what were those "utilization pressures"? Increased outpatient services, outpatient pharmacy, and behavioral mental health services (healthcare). Big Picture: CVS Health isn’t just any company. It's a behemoth with sprawling operations, including Aetna, a CVS Health Company (a major insurer), CVS Caremark (a leading pharmacy benefit manager), and a vast healthcare workforce through CVS MinuteClinic and Oak Street Health. Despite these extensive resources and their near-monopolistic vertical in the healthcare industry, the focus turns to profits over patients (aka margins over members). The Problem: Incentives. Medicare Advantage insurers and administrators love the upfront capital from Centers for Medicare & Medicaid Services (aka taxpayers), but really dislike it when patients actually need to use their services (which drains their capital) or CMS cuts their reimbursement due to quality concerns. To maintain profitability, they have three options: 1) shed members or 2) make it even more difficulty for patients to use services or 3) all of the above. And here's the problem, all options are bad for patients. Folks, it's beyond time to question the incentives embedded within our profit-drive health insurance system and in Medicare Advantage. We have to critically evaluate how business decisions by CVS (or United Healthcare or Humana) ultimately affect patient outcomes and #provider practice. To be clear, margins are necessary because it's true "no margin, no mission", but when a company can openly prioritize margins with potential repercussions for vulnerable, senior populations, it highlights the profound misalignments between healthcare needs and business strategies. #Healthcare #CVS #MedicareAdvantage #BusinessEthics #PatientCare ABIG Health Matthew Raffa MBA Meroka UNC Kenan-Flagler Business School MBA@UNC ESCP Business School

27

1 Comment

Sunday Morning Bathroom Read: Connecticut HB 5320 ( a/k/a the “Connecticut Public Defender and Risk Transfer Bill”) which recently passed the CT House of Representatives, creates a uniform application process and ELIGIBILITY criteria for financial assistance that requires not for profit hospitals to provide all medically necessary and emergency care services at the hospital’s full risk solely based upon an income level at 250% of the FPL ( $78,000 for a family of four) and without an asset test. Letterman Top 10 Market and CAA Implications: 1. The overall percentage of the US that earns an income level of 250% of the FPL is roughly 44%. I assume CT is similar; 2. Oscar and CIGNA recently announced that both will be leaving the CT small group market (https://lnkd.in/gmhH-gtd. ): 40% of the population effectively does not need insurance; 3. Plan design for CT employers moving forward: a) <250% of the FPL: MEC + CT Public Defender Plan; b) >251% of the FPL: RBR at the AGB% or ICHRA + fully funded HRA/HSA; c) Or depending upon the overall financial makeup of the group, ICHRA +CT Public Defender Plan; 4. Estate plan design (Risk Transfer): Ex):Business owner is diagnosed with cancer and has $1mm in cash and an income level of $500,000: Strategy: Slash income to 250% of the FPL and move this individual to the CT Public Defender Plan. There is a full risk transfer to facility and personal and business assets are unequivocally protected; 5. Joe lunch bucket (who has chronic back problems) is awarded a $100 a month raise which puts him above 250% of the FPL and on the company health plan. Maybe he declines the raise until his back gets better because the pay increase COSTS him more by being insured and paying premium; 6. Stop loss: For policies issued to plans in CT, I would include a provision that provides that claims are not subject to reimbursement in the event that an individual was eligible for financial assistance; 7. CAA Fiduciary Compliance: If the facility is "charging” FAP eligible patients its AGB percentage (40% of the CT market), shouldn’t everyone else get that rate? Medicaid, Medicare, Percentage of Walmart and CASH; 8. Claims data= medical, RX AND member financial information provided at the time of enrollment; 9. Office Linebacker: The Connecticut Health Systems Planning Unit; 10.Families that earn <250% of the FPL might just get a nice raise… . Happy Mother's Day to all of the mom's.

31

5 Comments

The Defense Health Agency (DHA) has awarded 11 companies positions under the unrestricted vendor pool of a potential 10-year, $43 billion follow-on contract to provide medical staffing support services for U.S. military health care facilities. The Department of Defense said Wednesday Medical Q-Coded Support and Services-Next Generation is a multiple-award, indefinite-delivery/indefinite-quantity contract that calls for contractors to recruit, qualify and provide qualified medical contract personnel to support direct patient care and other health activities at DHA hospitals and clinics across the U.S. and its territories. The performance period will kick off in June and run through the end of May 2034. The awardees are: Decypher Health Services, Epic Government, KBR (NYSE: KBR), Loyal Source Government Services, Luke & Associates, Matrix Providers, Optumserve Health Services, Spectrum Healthcare Resources, The Arora Group, U.S. Got People and Vesa Health & Technology.

1

Aetna, a CVS Health Company is kicking 1M seniors to the curb. Walmart Health dumping 35k was chump change. The list is going to grow LONG and there will be millions of seniors losing coverage. You see this little thing called HCC v28 packs quite the punch. I've been seen as a cross between chicken little and a Karen for months now about v28 (sorry to everyone named Karen). We are going to see MILLIONS disrupted this fall - public service announcement to any insurers looking to "buy" MA - lives it's your lucky year! Election year politics are complicated Andrew Schwab But in defense of the insurers Lee Bowers, if you are suddenly faced with losing 5-30% of your topline revenue on business that for many is 5% (at best) EBITDA you better do something fast. The thing is, the insurers are just the tip of the iceburg. Other than the seniors of course, the providers are where it will get really ugly. We are going to see thousands of provider withdrawals from Medicare Advantage and worse yet bankrupties. Insurers like Humana are legendary for passing off the cost of care financial risk on the providers and quite frankly it's the only long-term path to profitability for most PCPs/clinics. But the vast majority of providers are barely cutting it with their benchmarks of 2023 so when the final phase in of v28 hits in January 2025, they will likely be so upside down they have no choice but to abandon the cause. Preston Alexander I know you know this! Here is where my hope springs eternal polyana side comes to bear. If we use this black swan event (Colby Schaeffer you will be proud of my word choice here) to reimagine our sickcare ways into healthcare, we will weather the storm just fine. That's where this little gem of Lifestyle Medicine #foodishealth #regenerativemedicine I've been mentioning can take center stage as a white knight. Because when you suddenly get 15% less in benchmark for a diabetic patient it's okay becuase you will save more than that when you #justreverseit lifestyle disease. You know it's not woowoo - as Martin Tull reminded me earlier this week - not only is it a board certification, it's the basis of most of our actual clinical guidelines, those that people just aren't trained to practice and teach. Erin Martin, MASM Katie Stebbins Carter Williams Gebre Nida MD, FACE, DipABLM Alex Sommers, MD, ABEM, DipABLM Melissa Sundermann, DO, DipABLM, FACLM Caroline Collins, MD, DipABIM Anyone finally ready to build that "healthspital" with BP2 Health yet? Neil M. Meltzer, MPH, MHA John D. Couris Randy Haffner Feby Abraham If you are still reading this you might want to join our first live recording of The Reverse Mullet Healthcare Podcast tomorrow at 10:30am where we will talk about this along with other hot topics. David Pavlik Justin Politi https://lnkd.in/eEK8a9mw

42

33 Comments

While still under the watchful eye of the #FTC, and to retain clients and appease criticism over their role in rising drug costs, major #PBMs are launching a plethora of transparent and cost-effective models: 📂 Built upon the foundation of last year's "Cost Made Clear' program, next year, UnitedHealth Group's Optum Rx will roll out its value-based "Clear Trend Guarantee, (which) combines costs that used to be separated out, including retail pharmacy, home delivery, specialty drug, and rebates, into one single per-member price, according to a Monday release". 💊 CVS Caremark, with a program based on the true cost of drugs, aptly named 'TrueCost', and Express Scripts by Evernorth, with its version of cost-based pricing, are already on the grid with their solutions. All or many driven by the interest in Mark Cuban's Mark Cuban Cost Plus Drug Company, PBC model. In any case, the benefits and goals of these programs: 😊 Simplicity; easier to understand and navigate program nuances 🔎 Promote transparency, to allow sponsors, employers, and insurers to better manage drug spending, to seek the most cost-effective pathways 🎱 Improve predictability of drug costs for patients    #PharmacyBenefitManagers #DrugCosts #UHG #CVS #Caremark #ESI #ExpressScripts #Evernorth #CostPlusDrugs #MarkCuban #Healthcare

4

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

CMS is proposing a 2.8% decrease in the conversion factor under the CY 2025 proposed rule. On the blog, #ECGMC’s Jim Donohue, Dave Wofford, and Heather Flynn Kearney explain what it means for physician groups. #medicare #physicianfeeschedule

1

I'm sure everyone is aware of this news, but just to make it clear: The payers are in trouble. Profitable growth will not return until they find ways to reduce operating, back-office, and administrative costs, because high Medical Cost/Care Ratios are here to stay. As someone who has been privy to large payer operations, I can say there is significant room for improvement. However, bureaucracy and slow technology adoption continue to be major impediments. Luckily, the document-based, fax-oriented healthcare business model has the potential to overcome some of the most manual and mundane back-office problems by utilizing GenAi and LLMs, resulting in 200-400 basis points of additional profits. Yet, the inclination to develop their own solutions, or the desire to align with big brands like OpenAI, Microsoft, and Google, will likely result in nothing more than press releases and superficial market strategies. I worry that their natural tendency to cut costs by reducing headcount will perpetuate the inefficiencies, create backlogs, and ultimately reduce quality of care. #healthcare #healthinsurence #cvs #aetna #genai #llm #artificialintelligence #ai #technology #deeplearning #tech #innovation #data #dataanalytics #business #datascientist #automation #analytics #medicare #carequality #backoffice https://lnkd.in/g9Dbqacs

85

16 Comments