Michael Peters

Healththink Post#12. I can understand why retail giants have pursued primary care--(1) new revenue streams, (2) additional boosts to lagging store sales, and (3) low cost equipment, staffing, and overhead costs. Makes sense. But the economics of fee-for-service primary care in the US can be challenging. Large health systems can use primary care to control patient flows to their facilities and also drive more lucrative specialty care. I don't see the same upside for the retail giants as their ability to leverage primary care to support other service lines through vertically integrated services is limited relative to traditoinal heatlhcare. Hence, we hear of WalmartHealth announcing the closing of 51 stores. #Cicero #healthcare

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I'm trying to figure out why don't health plans offer multi-year contracts. Value to insurers: lock-in ARR / prevent customer churn. Value to members: insurance plan incentivized to pay for preventative care The best explanation I've heard why this doesn't happen came from Rebecca Mitchell, MD: Payers don't know how medical prices will inflate beyond a year, making pemium pricing / underwriting difficult. Surely this could be easier at an payvider though, yeah? I imagine the health plan at Kaiser could get better insight into future year physician contracts, hospital contracts, etc. Why else doesn't this happen today?

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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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🔎 Senators See Possible Conflicts of Interest in Health Care Pricing Tools The chairmen of two Senate committees overseeing health policy, Ron Wyden of Oregon and Bernie Sanders of Vermont, are looking into the practices of data analytics firm MultiPlan. Concerned about companies prioritizing their own profits over patient well-being, the senators are investigating MultiPlan's business model, which recommends lower payments to medical providers. This model could lead to a conflict of interest, as MultiPlan and insurers can collect higher fees when payouts are lower. The senators have called on MultiPlan to discuss their investigation and address concerns raised by a recent New York Times article. Read the full article here: Senators See Possible Conflicts of Interest in Health Care Pricing Tools MultiPlan has stated that they are working with the Senate committees to explain the complexities patients face when choosing high-priced care outside their networks, emphasizing their commitment to making healthcare transparent, fair, and affordable for all. This inquiry reflects the growing scrutiny of MultiPlan, which has faced allegations of anticompetitive behavior and collusion with insurers to fix prices. The Department of Labor also has ongoing investigations into the type of pricing services provided by MultiPlan. The attention on MultiPlan highlights the importance of employer-based health insurance, which is the most common way Americans receive coverage. Employers are increasingly looking into the cost of administering their plans and are frustrated by limited access to claims data. Legislation has been introduced to address this issue, requiring insurers to provide employers with claims data. As the investigation unfolds, it remains to be seen how MultiPlan and insurers will address concerns and ensure that patient well-being is prioritized over profits. #HealthCarePricing #PatientAdvocacy #HealthInsurance #DataAnalytics #SenateCommittees

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Latest Kaufman Hall report: The hospital industry’s financial performance seems to be stabilizing, BUT there's a widening gap between the highest- and lowest-performing organizations. "The hospitals that have been able to maintain financial health throughout the last few years are the ones who have taken care to adopt a wide variety of proactive cost-saving and growth strategies." 🤔 Has your organization adopted innovative cost-saving strategies to maintain or improve its financial health? 💡Optimizing financial assistance with the help of technology creates a win-win for patients AND providers. #healthcarefinance #hospitalfinance #revenuecycle #healthtech

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Keep our rurals open but if you really want to help get the foreign equity owned GPO that sets the pricing for our hospitals BANNED from our state. Economies of scale are used by Vizient against Oklahoma rural hospitals. If you have 13 tiers, hidden tiers, and tier maxes…that’s not a contract, that a free for all nightmare of a scam we all fell for. Their awful written tiered agreements force our rurals to pay more for the exact same items that our large hospitals pay less for. Example box of gloves a large hospital system in the state will pay 6-8 bucks for a box of 250 exam gloves. That same box for a rural EMT? 24 bucks. There is no price transparency and you are forcing patients who live in rural areas to pay more because of the lack of infrastructure by the corporations serving them to effectively and economically get goods and services to these hospitals. And distributors who whine about the cost of delivering to rural hospitals all while posting BILLIONS in profit every quarter are the first on my 💩 list. Let’s keep our rurals open but let’s make them more profitable so that they can continue to add much needed services and gainfully employ more community members.

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AccendoWave - A Pain #Data Company Health plans obligated to pay reasonable costs for workers’ care are grappling with wide price ranges in newly disclosed hospital data, which shows some employers pay thousands of dollars more for the same services in the same facility. For instance, employer plans with at least 10,000 members paid prices varying from more than $5,500 to less than $1,000 for a common gastrointestinal procedure at Palm Beach Gardens Medical Center in Palm Beach Gardens, Fla., according to March 2024 data compiled for Bloomberg Law by Turquoise Health, a price transparency platform that works with health-care industry stakeholders and consumers. 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.

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Individual insurance markets such as ACA Marketplace (aka Obamacare) and Medicare Advantage have annual regulatory changes that means plans annually evaluate expansion, exiting, or scaling back their footprint. BCBS Kansas City exited the Medicare Advantage market with their 32k members which caused me to think about those scenarios. This is not a post about the impact to the BCBS KC members nor how BCBS KC made the decision since it's a tough one and I have the same view from the balcony as my favorite Muppets, Waldorf and Statler. 𝐇𝐚𝐭𝐞 𝐭𝐡𝐞 𝐆𝐚𝐦𝐞, 𝐧𝐨𝐭 𝐭𝐡𝐞 𝐏𝐥𝐚𝐲𝐞𝐫𝐬: Regulatory and price change is a constant and individual members are making annual decisions. It's more like a cyclone than tail winds and head winds which means plans have to decide their threshold or risk being whipped around by the wind. 𝐊𝐧𝐨𝐰 𝐰𝐡𝐞𝐧 𝐭𝐨 𝐟𝐨𝐥𝐝 𝐭𝐡𝐞𝐦, 𝐤𝐧𝐨𝐰 𝐰𝐡𝐞𝐧 𝐭𝐨 𝐡𝐨𝐥𝐝 𝐭𝐡𝐞𝐦: At some point, the regulatory conditions get more favorable and plans that exited consider re-entering. It's always more costly to re-enter than you think due to acquisition costs, regaining market trust, and you have to offer lower-prices/richer benefits than the plans that stayed. 𝐍𝐞𝐯𝐞𝐫 𝐜𝐨𝐮𝐧𝐭 𝐲𝐨𝐮𝐫 𝐦𝐨𝐧𝐞𝐲 𝐰𝐡𝐢𝐥𝐞 𝐲𝐨𝐮'𝐫𝐞 𝐬𝐢𝐭𝐭𝐢𝐧𝐠 𝐚𝐭 𝐭𝐡𝐞 𝐭𝐚𝐛𝐥𝐞: What about staying in the market and shrinking your service area? There's often regulatory rules against this approach, fixed costs don't go down, and your market will still consider that to be an exit. While this can be an appealing middle ground, it doesn't usually pencil out. Also, I just quoted more Gambler lyrics since it's fun. The opening line doesn't really have anything to do with the commentary. 𝐔𝐩𝐬𝐢𝐝𝐞>𝐃𝐨𝐰𝐧𝐬𝐢𝐝𝐞? This is the only truly helpful information that I am offering. A talented CFO that I worked with drilled into my skull that you also have think of if the upside is greater than the downside for staying in the market. To simply paraphrase, if there's a 50% change of making $1 million, but losing $10 million, well to quote my new favorite song, 𝘛𝘩𝘦𝘳𝘦'𝘭𝘭 𝘣𝘦 𝘵𝘪𝘮𝘦 𝘦𝘯𝘰𝘶𝘨𝘩 𝘧𝘰𝘳 𝘤𝘰𝘶𝘯𝘵𝘪𝘯'/𝘞𝘩𝘦𝘯 𝘵𝘩𝘦 𝘥𝘦𝘢𝘭𝘪𝘯'𝘴 𝘥𝘰𝘯𝘦 https://lnkd.in/gKMjhjGW

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Yesterday, we proudly concluded our 17th Care Collaboration Conference in Portland, Oregon. This event convened leaders from across the healthcare spectrum, including acute and post-acute care operators, to share insights on reducing unnecessary hospitalizations—translating into significant savings for health plans. We used actual live customer data to show the potential of these savings to be reinvested as "gain-sharing dollars," rewarding the exceptional quality of care provided.    Initiatives like these are pivotal in advancing true value-based care, where all providers, including skilled nursing facilities, are rewarded for the quality and efficiency of their services. We are navigating exciting times as we shift towards more sophisticated reimbursement models that commend high-quality care.   At @PointClickCare, we are dedicated to unlocking your potential, regardless of your current platform use. Interested in how health plans view your operations and how to align with value-based care principles? Our VBC Innovation team is eager to assist. Let us explore the possibilities together and elevate both your care delivery standards and financial performance.   #HealthcareInnovation #ValueBasedCare #CareCollaboration #PointClickCare #HealthcareConference #PatientCare #HealthcareReform  

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AI is buzzing in the healthcare revenue cycle space. The idealist in me feels the best hope for sustained positive financial outcomes will rely on closer collaboration between providers and payers. The realist, though, understands the financial urgency health systems face. The automation game may be the only way to establish the bargaining power needed to level the playing field so that more productive conversations can take place. https://lnkd.in/e4w2cVtZ #healthcarerevenuecycle #automation

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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

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Great insight and analysis in our most recent signature research, which dives into where health payer executives are focusing their investments right now and how shifting to a data-driven mindset can create value. https://lnkd.in/ep7U_6Dt #analysis #research #healthcare #payer #investment #digital #data #ValueCreation

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If you are a #340B CE, check out this article by our 340B expert, Stephanie Caiazzo, MBA. She provides great insights for any CEs considering #referralcapture.

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CMS is winding down financial assistance to providers that had Medicare payments disrupted by the cyberattack on Change Healthcare. CMS will no longer accept requests for advanced payments after July 12, according to a June 17 news release from the agency. It provided $2.55 billion in advanced payments to 4,200 Medicare Part A providers through the program and $717.2 million in payments to Part B providers. CMS has been repaid 96% of the advanced payments it issued, according to the release. Change Healthcare, the largest healthcare claims clearinghouse in the U.S., was hacked by a ransomware group in late February. The outage led to disruption across the healthcare system. CMS established its program to provide advanced payments to providers struggling to receive payments in early March. The majority of Change Healthcare's systems were restored by mid-April. UnitedHealth Group, which owns Change Healthcare, has provided $6 billion in assistance to affected providers. In its release, CMS said any providers still having difficulty billing or receiving payments should contact Change Healthcare.

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Recent court decisions have caused CMS to recalculate Medicare Advantage Star Ratings - which will generate increased bonus payments for some plans as extreme outliers are not discounted from the calculations. But note: this decision was made based on the Administrative Practice Act (a federal law governing how federal agencies do their work) rather than the substance of the action; smart money will expect future rulemaking to comply with the decisions and further modify the calculations. The takeaway for practices and plans is to take the win today but not rest on these decisions: Providers, do your absolute best to deliver the best care, and Plans, invest in practices doing the work with your patients now for long-term success. https://lnkd.in/gSRFcuMs

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Adapting to regulatory shifts is crucial for maintaining competitiveness in the MA market. Staying ahead means leveraging accurate data and strategic collaborations. Learn more about how Advantmed’s Quality Improvement services can help  https://lnkd.in/gHeXBQTD #CMS #STAR #QualityImprovement #RecordRetrieval #Advantmed

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"The broad enthusiasm for generative AI is reflected in the investments in generative AI efforts targeting healthcare," says Kyle Wiggers. Collectively, generative AI in healthcare startups has raised tens of millions of dollars in venture capital to date, and the vast majority of health investors say that generative AI has significantly influenced their investment strategies. Healthcare faces numerous challenges, including the aging population, chronic disease burden, workforce shortages, and disparities in access to care. AI startups develop tools and technologies to address these challenges, such as telemedicine platforms, digital health interventions, and decision support systems. We have to remain ready for what lies ahead! #GenAI #Investments #Healthcare #Startups #HealthInvestors

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