Joan Zoltanski, MD, MBA

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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As our population ages, the strain on our healthcare system will continue to face unprecedented challenges, especially in caring for individuals with complex care needs. Coupled with this crisis, is an opportunity, to leverage new technology and innovation that can reimagine care delivery and the care experience. Questions we ideate on at AlayaCare include: How might we imagine, enable and empower physicians, nurses, therapists, and personal care aids to use technology to improve their practices and scale working in integrated care teams to keep people in their homes, where they want to be. One of the ways that we are answering these questions is by introducing the first-ever Large Language Model (LLM)-based smart AI assistant for home-based care. This new AI assistant will aid home care providers by providing real-time clinical decision support, reducing administrative burdens, and enabling more focused patient-centred care. Our goal is to mitigate risks of adverse clinical events, and hospital or institutional readmissions, but going further, perhaps one day even preventing them altogether. We want to optimize care schedules to make care providers' days just that much easier so that they can care for more individuals. Our true north is to find efficiencies and improve the quality of care that is being provided so that more of our loved ones can receive care in the place they call home. Thank you to the invaluable partnership of DIGITAL, Canada’s Global Innovation Cluster for this investment, trust and partnership as we continue to work to transform home-based care. https://lnkd.in/gN5Debhs

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EXCITING NEWS IN HEALTH POLICY!!! The Centers for Medicare and Medicaid Services propose introducing baseline requirements for hospitals and critical access hospitals (CAH) in obstetrical services, marking a pivotal step towards revolutionizing maternal healthcare. The proposed rule can drive robust maternal quality improvement initiatives that set foundational standards for the organization, staffing, and care delivery within obstetrical units. Safeguarding emergency services readiness and establishing seamless transfer protocols for obstetrical patients can significantly enhance the quality and safety of maternal care. Furthermore, the rule requires annual staff training on evidence-based maternal health practices and cultural competencies, equipping healthcare professionals with the knowledge and skills to provide compassionate, high-quality care to every mother. This policy intervention promises to elevate the standard of maternal health services nationwide, ultimately saving thousands of lives and improving outcomes for countless families. https://lnkd.in/eAPr6Tg9 #MaternalHealth #QualityCare #HealthcareReform #SafeDeliveries #MaternalWellness #CompassionateCare

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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.

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The biggest EHR overhead for Healthcare providers is cognitive. It comes from a presentation layer that does not mesh well with our thirst for synthesis or how all the myriad of concepts fit together. They also do a terrible job at scaling our cognition from higher level concepts to lower level concepts. This is the essence of modeling. Let's start a movement towards modeling/design tools in healthcare.

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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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In my weekly piece, I discuss AI-based services in healthcare. The integration of AI-delivered healthcare services is poised to revolutionize patient care, but a significant question remains: will payers equitably reimburse these services compared to care provided by human practitioners? my piece delves into the financial implications and policies surrounding AI in healthcare, highlighting the necessity for fair compensation frameworks. It emphasizes the potential benefits of AI for enhancing healthcare quality and accessibility while advocating for equitable reimbursement structures. Follow https://lnkd.in/ewwss6wy

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Focused Factories and “Experts aren’t surprised Optum is closing its telehealth unit” Optum’s closing of its telehealth unit is no surprise to me! I predicted the failure of everything-for-everybody care offerings, like Optum’s (https://lnkd.in/eV4Hxuzs), in my Market-Driven Health Care book (Addison-Wesley Publishing Company, 1996). I urged reorganization into focused factories that provided complete preventive and therapeutic care for specific diseases and disabilities. Although the market for these focused factories is immensely large—in the hundreds of billions of dollars for most individual chronic diseases—the everything-for-everybody providers hated this prediction. They subsequently overrode my urge to focus with vertical and horizontal mergers that created morbidly obese everything-for-everybody providers. Their promised economies of scale were nowhere to be seen—prices rose at increased rates—but the “value” crowd assured us that all was terrific.   I wish them well. Health care is so important to society. Value pricing is important but totally infeasible for the everything-for-everybody providers whose outcomes are impossibly difficult to relate to costs.   Focused providers, such as the virtual PT provider Sword, mental health provider Marvin, and the PCP IT enablers, such as Aledade or agilon, will ultimately force the reorganization of the care-delivery system. (View my cases on these companies here: https://lnkd.in/e_aX9YHV)   Of course, the success of any of these focused firms is hardly guaranteed. Even in these relatively modest focused offerings, execution reigns supreme. And Federal regulation must support this transformation (three cheers for Ms. Kahn of the FTC). But Optum’s closing is a good indicator of the transformation in which focused providers will nibble away the fat of the everything-for provider system and provide better accountability for their outcomes along the way.

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☝ Don't Miss the Application Deadlines for the ACO Primary Care Flex Model! CMS is accepting applications for the ACOs Primary Care Flex Model until August 1, 2024. Interested organizations must apply as new or renewing ACOs to the Medicare Shared Savings Program (MSSP) by June 17, 2024. The ACO PC Flex Model will launch on January 1, 2025, and run for five years. Low-revenue ACOs participating in the Shared Savings Program can apply to the ACO PC Flex Model. This innovative model aims to increase the number of low-revenue ACOs and enhance primary care payment through a Prospective Primary Care Payment (PPCP) option, shifting payment from fee-for-service to a predictable, monthly payment. 💲 Enhance primary care payment and innovative care delivery  📉 Narrow Disparities in health care outcomes  🔻Reduce program expenditures while preserving the quality of care  💪 Strengthen participation incentives for new and low-revenue ACOs 💰 Base Rate and Payment Enhancements  💴 One-time Advanced Shared Savings Payment Health Equity Strategy to drive accountable care and advance health equity #ACOPrimaryCareFlexModel #HealthcareInnovation #PrimaryCare #AccountableCare #Medicare #HealthEquity #SustainableHealthcare #ValueBasedCare #VBC #RiskAdjustment #PPCP #SharedSavings #CMS https://lnkd.in/gmiKZsHM

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It is evident that physician payments skew towards interventionists and proceduralists thereby limiting #primarycare payment, relatively. But a stat in this Health Affairs’ article caught my eye: To increase primary care supply by just 1%, the payments for primary care must increase by 4% or $1.6 Billion. To me, this means: 1. Value over Volume: Despite over two decades of discussion (with plenty of false starts), it's clear that the only sustainable payment model is one that prioritizes value over volume. 2. Re-architecting Care Delivery: There is not a human solution to our primary care workforce crisis, especially with an aging population. The way care is delivered must be re-architected that drives patient autonomy, access, affordability, and quality.

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It’s Sinking In: It Ain’t Over I was honored to participate today in the 340B Report-sponsored discussion about the status of the program at an incredibly informative Association for Value-Based Cancer Care meeting. My biggest takeaway?: the #340B community has begun to grapple with the distinct likelihood that the fight over a rebate model didn’t end with Johnson & Johnson’s letter stating that it would, for now, “forego implementation”. It was a great panel discussion with Ted Slafsky, Barbara Straub Williams, and Jennifer Lockwood, MBA, ACHE—all incredibly knowledgeable and strong advocates for covered entities. It was interesting to look out on the sea of faces during the presentation. I thought I could see the light dawning on the audience as the panel spoke. “Oh, ok, I get it. This rebate fight isn’t over.” And if you read the PhRMA and Biotechnology Innovation Organization letters to the Health Resources and Services Administration (HRSAgov), HHS, which were reported on by 340B Report earlier today, the tone and content are, I think unmistakable. Gird yourself for battle, people. Those letters are precursors of the points both organizations will be making in their amicus briefs in the court cases to come. I got flamed for saying the JnJ letter wasn’t the end of this issue—I’m happy to bet a steak dinner that I was right. Any takers? #lifesciences #drugpricing #diversion #duplicatediscounts #protect340B #reform340B ed silverman

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Other great questions from Dr. Shannon I. Decker, PhD., MBA, MBA, M.Ed., M.Ed. ➊ What makes for great pre-visit planning? ➋ Are retrospective chart reviews a thing of the past? ➌ Who does education better, a coder or a clinician? Be sure to listen in full to hear our thoughts! And let us know your thoughts!

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This topic and these two experienced experts should be on your #Healthcareprofessional development bucket list! Sign up today! DM me and I’ll connect with more details!

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Reflecting on the implementation of structured, value-based care models: The foundation of effective clinical intervention is a deep understanding of the health system and its key stakeholders. These models must center on the individuals receiving care. Evidence-guided and value-focused care optimizes available resources within health systems, specialty programs, and health services, leading to qualitative and valuable care delivery. The result? Better resource utilization, improved outcomes, and enhanced individual health. This approach is essential for organizations that design true care pathways rather than virtue signaling or creating superficial content. Having been intimately involved in Value-Based Care design and implementation, I'm eager to partner with forward-thinking organizations to continue this vital work. The result - a healthcare system that truly serves its patients and stakeholders - is a goal worth pursuing. If you're passionate about transforming healthcare delivery, let's connect and explore how we can drive meaningful change together. #ValueBasedCare #HealthcareInnovation #ClinicalPathways #HealthcareTransformation #letstalk

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Home healthcare providers face increasing pressure from Medicare rate cuts and rising operational costs and unfortunately, the nurses and care team often feel the brunt of this pressure. "The Centers for Medicare & Medicaid Services (CMS) has proposed cuts to home health payments three years in a row. Though its last two final payment rules have not been as harsh as its proposals, they have still come with permanent cuts to payments. Providers have multiple gripes with these cuts. The first is over the payment methodology that CMS applies, which most providers and advocates strongly disagree with. The second is the rising costs that home health agencies have recently faced. While CMS is cutting home health payment in traditional Medicare, the cost of providing services has skyrocketed – namely due to the cost of labor." If you're a home healthcare provider trying to do more with less while also wanting to support your clinical team, please reach out. We're happy to help! #coordinista #HomeHealthCare #Efficiency #ClinicalOptimization #HealthcareInnovation #nurses #fieldcaredelivery https://lnkd.in/gS5z3-Jj

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Thank you Robert Oubre, MD (The Doctor of Documentation) for posting this information. The CDI professional can contribute to oversights in physician documentation through collaboration with physicians, physician advisors, and Case Management/Utilization Review. Collaboration is the key to achieving true "documentation integrity" from a quality of care and reimbursement perspective. The limiting factor is the current Key Performance Indicators CDI is expected to achieve that are nothing more than task-based activities that do not correlate with documentation integrity. CDI plays a vital role in physician documentation for all the right reasons including patient care, quality measures, and support of the revenue cycle in that order. Quality documentation supports optimally sustainable net patient revenue less prone to clinical validation and medical necessity denials and level of care downgrades. I have always believed and supported measures of denials as defects in physician documentation that CDI can address provided it is an expectation of the CDI profession. I call on ACDIS and AHIMA to take the lead in advocating for and promoting transformation in current CDI processes as Dr. Oubre's post suggests. Time to reject the notion that CDI stands for CMI increase through CC/MCC Capture as the main focus of CDI activity. #cdiprofession, #chasingthediagnosis, #chasingmoneythatnevermaterializes, #qualitydocumentation https://lnkd.in/eJYuS-gf

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Earlier today, #CMS issued a #Medicaid Final Rule codifying existential Quality, Access and Accountability requirements. Among other things, these new rules improve #AccessToCare and #HealthEquity by: ⏩ Creating a mandatory MCD Quality Ratings System (#QRS) containing 18 required #HEDIS & #CAHPS measures which mirrors #MedicareAdvantage & #Exchange #StarRatings programs and requires public display of ratings online  ⏩ Requiring 10- or 15-day maximum wait time standards for routine appts for OP MH/SUD, #primarycare, OB/GYN & 1 add’l state-chosen service ⏩ Requiring MLR reporting, and minimum 85% MLR if states set a minimum MLR target ⏩ Expanding/encouraging #VBP, #VBC and #APMs and codifies Provider Incentive requirements ⏩ Adding guardrails and clarity for use of ILOS, including enrollee rights/access and oversight (the MCD version of #SupplementalBenefits in #MA) ⏩ Codifying #QualityImprovement expense criteria  ⏩ Expanding/strengthening network adequacy and benefit/service availability requirements These rules require Medicaid MCOs to ensure actual access exists for the care and services beneficiaries are entitled to. Just as we've seen recently with CMS changes to #MA, #PartD and #Stars, today’s FR change the game. Especially in combination with the 2027/2030 #DSNP Alignment rules in the 2025 MA FinalRule, these new requirements represent the most change in MCD accountability in decades. Here are 3 practical things Medicaid plans can do immediately for success: 1️⃣ Identify a silo-buster. CMS is aligning programs to minimize burden. It will be hard, if not impossible, to be profitable and highly rated if MA and MCD use separate processes, vendors, provider incentives, etc. It will be even harder to pass along product-specific provider accountability via risk/VBC without cross-program synergy/alignment. #Silobust relentlessly! 2️⃣ Educate, re-educate, re-skill & up-skill. These 284 pages, combined with the 182 in this week’s Nondiscrimination FR and last month’s 1,327 page MA FR can’t be understood or operationalized in your team’s ‘spare time.’ Every person in every team needs to understand the #NewNeedsOfFederalFunding so daily decisions meet new regulatory requirements. 3️⃣ Know your communities, know your providers and know your members. #NextGen solutions in both MA and MCD will require us to know and understand the communities and patients we have the privilege of serving. CMS understands the seismic impact of these rules, and is giving multiple years to come into compliance with the #NewNeedsOfMedicaid. Adaptation will require every bit of the long runways, though it will be tempting to slow-roll transformation since the timeline is long. #WhatGotYouHereWontGetYouThere #Transformation > #TinyTweaks #LetsRoll ⭐ ⭐ ⭐ ⭐ ⭐

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CMS has a 41 year track record of abuses very specific to the 2621 counties lowest in health care workforce where hospitals have been closed by the hundreds along with countless practices. The new cuts will be a minor impediment to most providers, but it will mean termination or major compromise in more of these counties with 40% of the population in 2010 and growing to 50% by the 2060s as CMS accelerates the decline of what health care remains. The 2621 counties include 37 million rural people (75% consistent in behind) and 90 million urban people (32% fastest growing). These rural and urban populations are both behind in outcomes and drivers of outcomes. This means that CMS micromanagement is costly, burdensome, and discriminatory. There is no value to compromise and terminations of hospitals, practices, team members, jobs, and local leaders. There is no validity of volume to value in what remains of health care services in these counties that have half enough of all basic health access specialties, access barriers, underutilization, and inappropriate utilization. The CMS one size fits all designs have very specifically caused harm to vulnerable populations. heir designs have not had supportive or beneficent intent. They reveal their true colors by cost cutting again and again. They fail to properly study the consequences or listen to critique. Therefore they cannot give informed consent to legislators, leaders, and people left behind. They violate the Belmont Principles and must be held accountable - same as physicians and human subject researchers. The string of steady abuses across DRG, RBRVS, manage care, Readmissions, Star Ratings, and value based designs continues. Millions of excess deaths are by design based on the same calculations used in African American populations and the 2621 counties have 2.7 times more people. CMS plans pay less than cost of delivery and pay 15 - 30% less in these counties. The better employers with their better paying private plans that bail out CMS deficits by design, are missing from the 2621 counties. Even worst the government, health care, and education jobs that did have better insurance, are being cut or centralized away. Only Hill Burton 1946 to 1997 and the first decade of Medicare and Medicaid with inflation related higher payments have helped these counties. Since the 1980s and in reaction to runaway health care costs engineered by those doing best, there have been cost cutting designs that abuse those politically weaker, distant, and poorly understood - the most. They have never spared basic health access or most Americans most behind who will not be writing letters

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