David Gorstein, MD

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

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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

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Behavioral healthcare has many facets. Can your #EHR handle your complex needs? Core's recent blog post shares valid food for thought. 

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Great commentary and details to be considered from post by Deborah Williams Too few probably understand what you've posted, the other major part of the problem. Commercial insured populations (employers & employees) pay the price for government policy failures that represent major hits on company bottom lines or lead to more individual bankruptcies today. #employeebenefits #employers #commerialinsurance #epcouncil.org

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Dr. Jain...THANK YOU for this insight and support for the kind of work I do every day! Building complex geriatrics longitudinal care programs is where I cut my value based teeth! These programs - when structured with attention to detail - can create a profoundly positive impact. A fully integrated program that is carefully facilitated, orchestrated, and navigated WITH a patient quite literally changes lives. As a system we have to shift our thinking and embrace the FACT that cookie cutter medicine is NOT effective as well as the notion that precision medicine is not scalable, replicable or sustainable....because it CAN be. Been there, done that (and continue to do it) and have the results to prove it! At Synergy 3C, THESE are the models we build and have a track record of success! We would love to have a conversation with you about HOW these models can and do work! #complexpopulationhealth #complexgeriatrics #medicareadvantage

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Last week, Elion covered the AI prior auth space for providers. This week we're looking at it from the payer side. For payers, prior authorization (PA) is a necessary burden: important for utilization management (UM) and financial planning, but a nightmare to manage. After PA requests are sent in, payers have to process the request from various channels into a case, match it with clinical criteria, validate required information, review and make the PA determination, then respond and iterate through any appeals. As payers update their procedures with new clinical evidence guidelines and new diagnostics and treatments, managing policies and creating decision trees for PA decisions requires enormous effort. Payer-facing AI prior authorization platforms have a huge opportunity to streamline these workflows by: 📒 Improving rules-engine generation and updates from unstructured policy documents and PDFs 📤 Automatically processing PA requests across all channels ✅ Matching the case to the right clinical criteria, validating data completeness, and determining if policies have been met through machine learning models and generative AI 📬 Generating decision documents and automating appeals correspondence with providers Several vendors are already making strides in AI-enabled PA for payers. Banjo Health offers tooling both for the PA request and clinical decision policy creation workflows for health plans, TPAs, and pharmacy benefit managers. basys.ai uses LLMs to offer rapid ingestion of policy documents for fast integration and up-to-date policies. Cohere Health is one of the more mature vendors in the space, and offers a variety of products for UM. Co:Helm is a generative AI platform for payers, with initial use cases around enabling UM nurses to make complex PA decisions more quickly. Finally, GenHealth.ai has built their own large medical foundation model and is using it to enable both rapid policy ingestion and PA review. We see PA as the first place where payers will incorporate advanced clinical AI. Although PA denials should never be fully automated, vendors that can drive efficiency here stand to become a core part of payers’ clinical decision-making process. --- We received a number of interesting responses last week regarding the AI prior auth space. We're continuing to dive deep here, so please reach out if you're currently investigating it and would like to discuss.

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How does a $497k chart audit risk turn into a recommended $6.8M recoupment? Impact extrapolation, that is how. The rule now allowing the OIG to recommend larger recoupments are now in effect. This is the first of two audits published today. It isn't too often that the OIG publishes not one, but two, findings reports in a day. Let's dig into the first one. The article linked below is tied to a 2017 and 2018 date of service audit of high risk diagnosis codes by the OIG. Beginning with 2018 dates of service the OIG is able to recommend that dollar impacts reflect the extrapolated error rates from their reviews. This is highly controversial because of financial magnitude and the approach to extrapolation. This marks one of the first ones that I have seen. In this audit the OIG reviewed 240 conditions from the years in question. There are 8 conditions that were reviewed during the audit. They were stroke, heart attack, embolism, sepsis, lung cancer, breast cancer, colon cancer, and prostate cancer. What jumps out to me in this review is the sepsis category. This is the first time I have seen sepsis as a high risk diagnosis. In fact, sepsis and pressure ulcers are in the other review (which I will post shortly). The story continues to be the same. Acute conditions being captured when they often represent historical conditions. In fact for the cancers, strokes, and heart attacks a whopping 93.3% (168 of 180) were found to not be valid. This is in line with prior reviews. Organizations, both payers and providers, must have processes in place to identify and review these. For the sepsis patients, 30% were rejected. While higher than desired, this is significantly lower than other targeted conditions the OIG historically reviews. The call to action for organizations is simple: 1) Know your data- know what patients you have, what conditions they have, and what you are billing for your patients. 2) Increase scrutiny on high risk conditions- if a patient has a stroke, heart attack, or cancer that is captured by a PCP or captured only once in a calendar year it is worth a second review. 3) Educate providers- it is critical to educate providers on the difference between active conditions and historical conditions. There is often no ill intent by providers rather it is matter of coding appropriateness. Leverage your experts to help them know the rules. Enjoy your Wednesday! https://lnkd.in/eX7tjgyB

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Per Andrew Witty, CEO of United Healthcare: ..."I think [it is] important for the country that we [UHC] own Change Healthcare." (n8- he's not kidding?) UHC's CEO goes on to say, "This cyberattack has unfortunately created another true validation of why that was the right thing to do because it meant UHG was in a position to resolve this much more quickly than I think would ever have been imaginable in a stand-alone situation." I want to ask: What is He Smoking, and What Does He Think We Were Born Yesterday - but that would be inappropriate. So it goes n8 PS Where is the healthcare press to push back on this nonsense? PPS:  despite Change Healthcare paying the ransom for their files to be deleted by hackers, another cybercriminal group called RansomHub has begun leaking files online, demanding a payment of their own. The affiliation between Blackcat and RansomHub is unknown, but the latter is claiming on the dark web to be the actual culprit behind the breach.* *https://lnkd.in/gwDFEYFm #healthsystems #hospitals #healthinsurance #medicareadvantage #valuebasedcare

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HSG Advisors Dashboard is changing the game for healthcare leaders. It provides information they've never had access to and makes it actionable so leaders can make informed decisions about competitor dynamics, service line growth, access point strategies, and much more! Ready to see a demo? Set up a time on my calendar. https://lnkd.in/gAvyUkny #healthcareconsulting #healthcareleaders #hospital #hsgdashboard #healthsystem #claimsdataanalytics

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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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Guaranteed Rx Rebates: A Dilemma -For small, self-insured hospitals (especially independent hospitals) predictable revenue is more important than net, lowest cost therefore, a guaranteed rebate carries a significant amount of weight in the buying process (think RFP process from the broker/client perspective) -Higher rebates almost always correlate to higher drug costs (i.e. brand name drugs) as this is a simple math (%) equation -As drug inflation (price of drugs) increases throughout the year, correlating rebates on those drugs also increase (see above point) -Guaranteed rebates (offered by your PBM) involve risk meaning, if the calculation/forecast falls short of the guarantee amount the PBM eats the loss. If the actual rebate exceeds the guaranteed rebate amount-the PBM keeps the surplus. PBMs are masters at projecting and retaining surplus. Clients (employers) have no idea of the revenue that the PBM is making above the guaranteed rebate(s) level How to overcome the Dilemma: Create an agreement (hybrid approach) that begins with a guaranteed rebate process (for budgeting and cash flow) but requires monthly reviews which allows for critical formulary modifications to ensure that you are working toward lowest net cost. Create a path for the grandfathering in of current employees (protects the guaranteed rebates) while simultaneously onboarding new employees to an evolving formulary designed for lowest net cost (Rx). Also, demand from your PBM that you engage in a shared risk approach meaning, the PBM is rewarded for their risk but rebates (dollars) above a certain % is passed through to you, the client. Make sure your pharmacists and key HR personnel have a seat at the Pharmaceutical and Therapeutics Committee (P&T) table to make key decisions such as prior authorizations, formulary modifications, etc.

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