Brett Hudspeth

Providers and health plans have been working on their Fee for Service payment processes for decades (still work to be done there), but the data flows needed to support Value Based Care arrangements are in their infancy. Organizations involved in Value Based Care (VBC) should consider using modern processes (like APIs) and standards (like HL7 FHIR) to exchange: · Rosters of members attributed to VBC populations · Financial performance on VBC contracts · VBC contract details · Patient care gaps for VBC contracts · Clinical quality performance · And the list goes on In his interview with Rick Daly from HMFA, Deepak Sadagopan talks about why his team is building the data infrastructure to support VBC and why it should matter to you. https://lnkd.in/ggKeA985

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More interesting #news today on #carecoordination and transitions of care, this time specific to bundled payments for hospitals and the #TEAM model. #CMS #Healthcare #reimbursement

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As policymakers consider changes to the Medicare Advantage (MA) program, it's essential to acknowledge the diversity of D-SNP and MA-PD plans. A one-size-fits-all approach may fail to address the unique needs of these plans and lead to unintended consequences for Medicare beneficiaries. Thoughtful and tailored policy decisions can help ensure that all beneficiaries receive the care and support they desire and deserve. Our new Association for Community Affiliated Plans (ACAP) report shares specific policy recommendations and options for consideration: https://bit.ly/4dHIpWj #MedicareAdvantage #DSNP 

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OIG ALERT- Another targeted condition review, the 5th this year, was released this week. While the penalty is only $297k, the risk found was 51X the penalty. I repeat... 51 times. In addition to the settlement with a health plan announced by the DOJ yesterday, the OIG also posted its most recent targeted review of conditions for a Medicare Advantage plan. These targeted reviews focus on conditions the OIG has identified as having an extreme likelihood for overpayment. Nothing is necessarily new in this report, especially since the dates of service were 2015 and 2016 dates of service. The details: -9 different clinical conditions were reviewed for potential over-capture. All 9 of these have been on prior reports. However, this is the first time vascular claudication has shown up in a 2024 report. I suspect that is because the dates of service are older and not representative of an increased emphasis on the condition. -73% of conditions reviewed failed to have supporting documentation. This number is consistent with prior reviews by the OIG. -Interestingly, depression and vascular claudication were supported in 93% of the reviews. This is on the high end and also one of the reasons the OIG has decreased emphasis on these conditions. -90% of heart attack, stroke, and cancer patients reviewed failed to have supporting documentation. The OIG found that in total the overpayment was $297k. However, this is due to the sampling was limited by condition and extrapolated payment penalties were not allowed for these dates of service. Had they been, the penalty would likely have been 51X higher since the OIG identified $15.3M of risk for these conditions. I expect that now that extrapolation is allowed we can expect to see more OIG reviews with larger penalties. Additionally, with yesterday's DOJ settlement with Independent Health and in particular the $2M penalty to former DxID CEO, I expect 2025 will bring more review findings. If you aren't reviewing your risk then you are susceptible for takebacks. https://lnkd.in/e_Sae-79

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Find out why Blue Cross Blue Shield of Michigan has been “so pleased” with its five-year partnership with Teladoc Health that it expanded its offerings from diabetes management to a full suite of integrated #virtualcare services. #IntegratedCare

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Clinical data is flowing more freely to health plans, but vital financial data is not getting to providers. U.S. provider organizations need to understand how information asymmetry will impact them and what to do about it. Here is my latest. https://lnkd.in/gZ-jnTJB #informationasymmetry #interoperability #valuebasedcare #healthtechmagazine

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Health care reforms could use a shakeup in 2025. Learn how: Medical Policy for most of America in created in conjunction with a Single Source and Healthcare coverage and payment is determination is already highly centralized. https://lnkd.in/eq9Ys4uX Big fan of AHealthcareZ and Eric Bricker, MD.

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What does the future hold for retail medicine and virtual care? Walmart is the latest to announce their health center closure. https://lnkd.in/geZpMTkS. This following Optum news, VillageMD closing in Nevada, Teladoc Health problems, etc. What comes next? This is another in a long line of examples that technology and even consumer willingness are not enough when the reimbursement environment does not support particular care models. Are we getting ready to lose all the lessons painfully learned during the pandemic? Or will new virtual care models emerge following this round of closures?

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Healthcare CIOs, CMIOs and other IT leaders, Tired of hearing from irate clinicians that IT “just doesn’t get it” or “support them”? Double their satisfaction and increase their trust in IT at the same time with uPerform. This study from KLAS shows how. #ehrsatisfaction #physicianexperience #clinicianwellbeing #ArchCollaborative

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Blue Cross Blue Shield of Michigan executive Bill Fandrich believes that generative AI, like ChatGPT, can be used in health insurance to provide patients with more clarity and personalized information to help ease administrative burdens and frustrations. Fandrich envisions using generative AI to bring together the volume and complexity of health insurance information and help individuals make the right choices and decisions. However, he acknowledged that people may be distrustful of a health insurer using generative AI and said that more specific guidelines and regulations would be helpful to address concerns over patient information use, bias, ethics, accuracy, and data access. https://lnkd.in/eQQfq7Vr #healthcare #healthcareinnovation #healthcareit #healthcareai #ai #genai

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OIG ALERT: The first OIG report since February came out on Friday. Not shocking but the findings continue to be consistent with previous reports. If you need help assessing your risk, let me know. The report that came out Friday looked at 2016 and 2017 claims that Independent Health Association submitted to CMS for risk adjustment. The OIG focused on 8 target areas seen to have consistently high false positive rates. In this case they found that 230 of the 247 conditions reviewed, or 93%, did not have documentation to support the conditions submitted. The total takeback for this $646k for the two years. However, if the results were extrapolated, as can be done beginning in 2018, the takeback would have been 10X larger at $7M. The areas reviewed included: -Acute Stroke: 100% incorrectly captured -Acute Heart Attack: 97% incorrectly captured -Embolism: 90% incorrectly captured -Lung Cancer: 100% incorrectly captured -Breast Cancer: 100% incorrectly captured -Colon Cancer: 97% incorrectly captured -Prostate Cancer: 93% incorrectly captured -Miskeyed Diagnoses: 73% incorrectly captured For my followers by now this shouldn't be an earth shattering report. One of our 45 best practices for a strong risk adjustment program is to have stops in place to prevent these claims from going out the door without a review. Stay tuned for more updates and summary stats that aggregate the findings from these OIG reviews. https://lnkd.in/ec2R9C-G

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Join us for a crucial session where we delve into the Health Equity Index. Learn how it's calculated and its significant impact on quality and Star metrics for Medicare Advantage plans. View the SOA Health Meeting agenda here: https://optumin.co/ssw6cc #Optum #SOA #HealthEquity #Medicare #Payer

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#PublicHealth experts have stressed the urgency of driving awareness about the deadly impacts of rising temperatures across the globe. Proud to see how CVS Health is answering that call. 👇 In a first-of-its-kind initiative, CVS Health announced an environmental health impact program to help people most vulnerable to extreme weather events — like #HeatWaves — that can worsen existing chronic conditions. Initially available to our Aetna members with a goal to expand, this initiative will use advanced environmental data analytics and enable our care managers to contact vulnerable patients with tailored recommendations. Heat-related illnesses are preventable with outreach and intervention. Our initiative aims to provide up to a seven days' warning in advance of an extreme weather event, giving our members critical time to prepare. Read more about our initiative: https://cvs.co/3WWQFgl #TeamCVS

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I did a webinar for our clients at Milliman IntelliScript about ONC’s Cures Act Final Rule and broke down accessing data with an IAL2 workflow vs. OAUTH workflow! I made some mistakes and got some facts flipped but overall I think I did a good job. Take a listen and share your feedback with me directly. I would love to build out the concepts of this webinar into more deep dives!

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"Gen AI 'mission-creep' is the biggest health IT and RCM threat I see right now," said Mark Townsend, MD, chief clinical innovation officer at Cincinnati-based Bon Secours Mercy Health. "Don't get me wrong, I believe in the potential of generative AI to help us work smarter and not harder. We are working hard to create new technology using generative AI, we are selectively investing in Gen AI, and Gen AI is not a panacea for patient care or for operational performance." "The mission-creep of gen AI is to oversell its potential and under-deliver on its performance, which absolutely requires a human being in the loop to validate every output," said Dr. Townsend. "Said differently, challenging ourselves to truly quantify the value of gen AI tools is a tall order at this point." https://lnkd.in/euaYzMD6

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Unpacking the CVS MA success #medicare #cvs Enrollment, Experience, Quality, Leverage, Simplification in 5 words. CVS Aetna has achieved significant success with Medicare Advantage through several key strategies: 1) Strong Enrollment Growth -- Enrollment Aetna has experienced industry-leading growth in Medicare Advantage enrollment: - They saw 15% growth during the annual enrollment period, reaching around 4 million total members. - Aetna attracted about one-third of the 1.7 million new Medicare Advantage beneficiaries in 2024. - They added 544,000 new members in 2024, bringing their total to 3.9 million beneficiaries. 2) Focus on Member Experience and Benefits -- Experience Aetna has prioritized offering compelling benefits and improving the member experience: - Every county where they offer a plan has options including $0 primary care with no monthly premium, $0 cost sharing for tier one drugs, and dental, vision and hearing benefits. - They improved by nearly one star in the Member Experience survey domain. - Aetna achieved 5 stars in Care Coordination and delivered 5-star performance for low member complaints and low disenrollment rates. 3) Quality Ratings -- Quality Aetna has maintained strong quality ratings from CMS: - 87% of Aetna Medicare Advantage members are in plans rated 4 stars or higher for 2024. - Their National PPO contract improved to an overall 4-star rating. - They achieved 5 stars in key measures like Breast Cancer Screening, Controlling Blood Pressure, Diabetes Eye Exam and Annual Flu Vaccine. 4) Leveraging CVS Health Assets -- Leverage Being part of CVS Health has allowed Aetna to offer unique capabilities: - They can provide access to MinuteClinics, CVS Pharmacy locations, Signify Health home visits, and Oak Street Health primary care clinics specializing in senior care. 5) Strategic Market Approach -- Simplification Aetna has taken a targeted approach to expansion: - They've focused on plan simplification and enhancing their value proposition for members. - The company has made strategic efforts to establish a strong presence in the Medicare Advantage sector. While Aetna has seen strong growth, it's worth noting that this rapid expansion has also led to some challenges, including rising medical costs that have impacted CVS Health's overall financial performance. However, the company is taking steps to address these issues and maintain its competitive position in the Medicare Advantage market.

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Provider dissatisfaction with #MedicareAdvantage plans is growing, threatening network adequacy. On the blog, #ECGMC’s Ed Moran, Chris Costa, and Joe Casini offer 3 considerations to help #payers improve provider relations. https://lnkd.in/gUxqjqAR

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🚨 Top 10 #PatientSafety Concerns for 2024. 📌 Have significant changes been made over the last decade? An important question is to reflect on what has been done, what we are doing, and what remains to be done.

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