Amy Boutwell, MD, MPP

If we want to see long-term investment in improving #HealthEquity, it can't only be done through short-term #grant programs from foundations. It has to be done through long-term payment policy that seeks to create lasting and durable financial flows toward specific equity-focused strategic objectives.   With this in mind, it’s great to see Boston Children's Hospital join Blue Cross Blue Shield of Massachusetts’ pay-for-equity financial payment model! https://bit.ly/3wqqDaM    Many aspects of BCBSMA’s pay-for-equity model are crucial to building sustainable improvements in equity, but one of the most notable is that it is driven by data. BCBSMA has helped set its health system partners up for success by investing in data that helps identify where equity gaps exist in key performance areas. New data collection systems gather better information from patient populations on race, ethnicity, language, sexual orientation, and gender identity.    BCBSMA team members use this information to create public health equity report cards for some of the largest health systems in Massachusetts, as well as report cards for individual health systems. Individual report cards help organizations understand how they compare on specific measures relative to their peers. With better and more refined data, providers and payers can see and tackle opportunities for improvement with greater clarity.    It’s been an honor for IHI to help BCBSMA advance its health equity journey. Congrats to them, Boston Children’s, and everyone out there that’s committing their time, talent, and resources to achieving more equitable outcomes.

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"Exploring the Crisis of Primary Care Wait Times" Digging into the pressing issue of primary care access, a striking statistic caught my attention: an unprecedented national average wait time for patients to see primary care physicians. It's clear we're facing a crisis that threatens not only patient health but the foundational principles of our healthcare system. The takeaway for us as healthcare professionals, policymakers, and advocates is multifaceted. This isn't just about numbers; it's a reflection of a deeper systemic failure that requires innovative solutions, strategic policy changes, and a renewed focus on healthcare accessibility. How we respond to this challenge will shape the future of primary care and, by extension, the overall well-being of our communities. For a deeper dive into the dimensions of this crisis and the potential pathways to meaningful reform, I encourage you to read the full article: https://buff.ly/4aXNlWj #healthcare #crisis #policy #hospitals

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Payers everywhere are facing challenges with Medicaid expenditure. With nearly all 350k NICU infants/year receiving Medicaid payments for an expenditure of over 40b it is not surprising that maternal digital health is a hot sector with companies like Maven Clinic raising investment on huge valuations based on metrics that demonstrate decreased NICU utilization. However after the baby is in the NICU only Firstday Healthcare is creating value based healthcare delivery options that support neonatologists enable earlier and safer discharge home providing value to the system and piece of mind to overwhelmed and underprepared parents and moving the delivery of healthcare towards the home and value based from the first days of life and beyond. https://lnkd.in/eRtRrJRp

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The STOP Obesity Alliance analyzed the state Medicaid coverage data for plan year 2023, with both the Medicaid Fee for Service and top Medicaid Managed Care plans for each state were analyzed. The review included the categories of comprehensive obesity care: nutrition counseling, intensive behavioral therapy, obesity medications, and metabolic and bariatric surgery. Overall, obesity treatment coverage was not covered in fourteen states, twenty-nine states had restrictive coverage, eight states had limited coverage, and no single state covered obesity care. In more detail, twenty-two states did not provide coverage for nutritional counseling, one state failed to provide any coverage for intensive behavioral therapy, obesity medications were not covered in thirty-two states, and only two states did not provide coverage for metabolic and bariatric surgery. Across all evidence-based obesity treatments, no state provided coverage for comprehensive obesity care, with all states applying various levels of exclusions, limitations, or restrictions for the coverage of obesity treatments. https://lnkd.in/eMwjSUMV

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Now live: Blue Cross Blue Shield of Massachusetts’ 4th annual health equity report https://lnkd.in/e2WFFSZ9 We publish these ~70 metrics every year to be transparent and accountable to our members, accounts, providers, and communities we serve. As usual, there is a methods section at the bottom of the report, including links to all previous years and data versions.

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Recommend: Excellent Moderation. I appreciated Nina’s comment about the lack of tested budget neutrality for the Medicaid waivers. What isn’t often considered is that these expansions push up Medicare DSH spending, without any improvements in services or access. Ryan mentioned their expected shopping list in a R Congress from work requirements for able bodied adults in the expansion population to a single site of services that cuts beneficiary costs. Re BB study, I find the lack of paycheck and other documentation for exchange subsidies to be incongruent with other welfare programs. In a scan, I see covered CA is specific about documenting the benefit of underestimating your income to receive a greater subsidy. It’s dishonest policy. See Paragon.

This article from Becker's Healthcare signals to me that the term "health equity" is not fleeting or just political fodder. To me, health equity is just good, reliable healthcare for all.. and traces right back to the Triple/Quadruple Aim, and pop health. BUT it does point out some very real challenges with data, integration, and program design that will be required for entities thrive in this "future of health," which seems like it will be even more centered on equity, data, and technology than it is today, given the massive workforce and operational bottlenecks we're encountering as an industry. Becker's reported that "most providers aren't ready to meet new health equity regulatory requirements" back in March. This was based on EY's Health Equity Outlook Report (which was also excellent) and is interesting for a couple reasons. 1️⃣ One is that very soon, there will be actual concrete measures that health equity initiatives will be tied to, much like our regulatory qualiy measures etc. This means there will be clear "outcomes" to strive for, even though I've said before that "outcomes" can and should be more than just regulatory measures. Still, when something is a required measure then people pay more attention. According to Becker's, "most provider and payer respondents indicated that as of today, they could not meet health equity-related regulatory requirements introduced by CMS, the National Committee for Quality Assurance, The Joint Commission and the FDA last year." 2️⃣ Two is that the "requirements that the fewest are prepared to meet are disparity root cause assessments (21%), culturally tailored services (24%) and social needs referral pathways (27%)." ------------------------------------ My take: To me, this reads as opportunity for new data and technology methods led by people (founders, providers, CHWs, etc.) with lived experience or who are more in touch with the communities being served. This is also illuminating the need for better data and more diverse voices, something that is not new or unique to health equity initiatives in the healthcare space. I gave a TEDx talk about the latter 5 years ago. But, the difference between now and then is that we may actually have a forced catalyst by way of these new requirements. Interesting times, interested to see how things unfold. ------------------------------------ Read the Becker's article here: https://buff.ly/49hYLTw The EY report Health Equity Outlook Report here: https://buff.ly/3xeEjFW Watch the TEDx Talk here: https://buff.ly/4a6Vl77 And learn about the upcoming US regulatory changes with health equity implications, also eloquently summarized by EY: https://buff.ly/3PFZFlB

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Indeed a turning point for women's health. I am not a political person, but this is something I can proudly support. Very proud of my friends Liz Powell, Jodi Neuhauser, and Candace McDonald for launching this Women's Health PAC who have the support of thousands of women in the healthcare industry. With more money, research, information, innovation, funding, and focus on women's health... everyone wins. Including men. This is not exclusive, this ensures inclusion of all people, especially women who have been excluded from most of the above including in healthcare. Equity ensures equality, and without a focus on women's health there will be not achievement of equity. #healthequity #healthequityforwomen #womenshealth #women #equality #womeninhealth #womenleaders #womeninleadership #womeninmedtech #PAC #womenshealthPAC

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Some transformative news from the Centers for Medicare and Medicaid Services (CMS) that could change the landscape of Medicaid. Here’s what’s happening: What’s New? ➡ State-Directed Payments: States can now direct Medicaid-managed care plans to pay providers at rates similar to commercial plans. This move aims to enhance access and provide vital support to providers caring for Medicaid patients. ➡ Codification of Payment Flexibility: CMS has formalized policies allowing payment rates up to the average commercial rate (ACR). Research shows that higher rates lead to better access to care, and now it’s official. ➡ Focus on Access and Equity: These changes are set to increase provider participation in Medicaid and bolster safety-net providers. This means better care for Medicaid enrollees, who often have complex health needs and are disproportionately people of color. ➡ Growth and Scrutiny: With directed payment spending on the rise, CMS is implementing new guardrails to ensure compliance and maintain fiscal integrity, including measures against pooling practices among providers. ➡ Future Implications: By 2028, these new rules could channel an additional $16 billion to $36 billion to hospitals. This will enhance Medicaid’s role as a competitive payer and improve access for enrollees. The Challenges Implementing these changes won't be without its hurdles: ➡ Ensuring Compliance: We’ll need robust systems to monitor and enforce these new rules. ➡ Managing Financial Impact: Higher payment rates are great, but they could strain state budgets, so careful planning is essential. ➡ Navigating Provider Taxation: Aligning with federal rules on provider taxes is complex and requires careful attention. ➡ Balancing Equity and Budget: It’s crucial to strike the right balance between fair compensation for providers and maintaining fiscal integrity. Why It Matters These updates represent a significant step toward a more equitable and accessible healthcare system. While there are challenges ahead, the potential benefits for Medicaid enrollees and providers are immense. #Medicaid #Healthcare #CMS #HealthPolicy #EquityInHealthcare #AccessToCare #HealthcareProviders #Medicare #HealthReform #PublicHealth

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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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This flew under the radar a bit but is noteworthy on several fronts: 1.State medicaid programs like Medi-Cal are notorious for running in the red - and reimbursing providers poorly. Prima facie, the intentions are good; but so are most of the roads to hell. 2.These funds came from a tax on health plans, and has been accumulating for some time. The state is also able to raise matching federal funds doubling the moneys available. They apparently have license to use as they see fit. 3. I am astounded that it's legal to use this money as a slush fund to offset the state budget deficit; but I've seen stranger things. 4.The CA state budget for Medi-Cal is over $150B and accounts for around 20% of the state's General Fund spending. (For comparison, the entire projected General Fund was $90B barely 20 years ago.). The state keeps expanding the parameter of services and constituents eligible for Medi-Cal; but the money is just not there. 5. Levying a tax on health plans in the name of addressing health equity disparities, only to divert the money to offset state budget deficits seems like a bad bait and switch. Ge Bai Marty Makary M.D., M.P.H. Anthony DiGiorgio, DO, MHA Adam J. Bruggeman, MD, MHA, FAAOS, FAOA

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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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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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Healthcare is a complex space. Not easy to understand, design to, or operate in.

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Not fair and balanced Advertorial for Private Equity A total conflict of interest Immoral to destroy healthcare for opportunity to work for companies that profit on ultimately destroying USA 🇺🇸 healthcare as we knew it. People that worked for CMS should be banned from working in industries that profited from the decisions and have connections for future decisions to destroy the healthcare fabric No discussion of the negatives only the positives Consolidation leads to fewer choices for patients The cons for patients outweigh the pros for the investors. Profits over care ultimately leads to rationing of the care that is not profitable Management of PE selects doctors to interface that benefit from a hard line approach over providers that see quality issues and patient safety as important Cheerleaders 📣 for the profiteers

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With changes in the Medicare Advantage risk model, slowed increase in Medicare Advantage county base rates, and downward pressure on Medicare star ratings—we are seeing broad evidence of retraction. Altogether, these changes amount to a significant cut to industry revenue. National carriers are announcing major cost cutting initiatives, withdrawals from unprofitable markets, and markedly slashing member benefits in an attempt to stay profitable. And some health systems are taking the unprecedented step of exiting Medicare Advantage (many of them non-profit) altogether despite the fact that 50+% seniors now use the program to access healthcare services. Taken together, some are calling these cuts “the great disruption.” Some observations: 1) Benefit “innovation” had gotten out of hand. To stay competitive and grab share, plans (including ours) were introducing unsustainable benefits that caught attention of members only to pull them back. This is going to stop. At least for now. (Traditionally unsexy) Benefit stability will win the hearts and minds of beneficiaries who will be tired of the yo-yo benefits they have experienced in our previously inflationary environment. If it’s too good to be true, it usually is and startups that funded growth through investment capital can’t do it forever. 2) Organizations that succeeded in Medicare Advantage risk through maximizing revenue capture will actually have to learn how to effectively manage care for older adults. This means providing rapid access to patients to help them avoid emergency rooms and hospital admissions. This means more proactive management of chronic conditions. This means managing their own utilization of low-value services. It’s a worthy challenge and time for put so-called high value healthcare organizations to the test. 3) As benefits come down to earth and there’s more parity, competition will be increasingly focused on effectiveness and service. Do you actually do what you say will do? Does your rhetoric match action? And this is a good thing. Service excellence along the value chain is what matters most to beneficiaries. It just hasn’t been what they valued most at point of purchase. Organizations that commit to radical consumer focus will win. 4) Brokers will be more important than ever to guide people to make good decisions about their plans. In an increasingly complicated marketplace (made more complicated by the IRA and changes to drug benefits), people who can help seniors truly understand their options and true out of pocket exposure will be critical. 5) Everyone partnering with everyone (brokers, plans, provider partners) is not a winning strategy. Deeper, narrowing partnerships will win the day. The “great disruption” will begin to play out this Annual Enrollment Period. Let’s just not forget that at the other end of everything we do is an older adult who relies on our service and care.

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Congressional efforts to get low-income Black and indigenous mothers equitable care via Medicaid covering doulas & midwives, while progress, must also advance outcomes-focused, team-based pay to address low Medicaid rates. Since California led the nation putting out our Medicaid doula benefit, I have heard many concerns about how this workforce can get paid in aggregate more than OB’s. We’ve heard infighting between OB’s, midwives, and doulas shift from concerns about competency and scope of practice to a more divisive issue - is everyone getting theirs. The solution seems simple enough - recognize the value of all professionals by paying for healthy, safe births for mamas and babies, that include all team members available and coordinating. Stop simply paying for x service or y team member only. If we focus on outcomes AND who’s on the payroll, health professionals, hospitals and health systems will eventually identify the right combination of team members for a given scenario and work to improve team dynamics. Outcomes and pay rates need to be risk stratified by a transparent, data-driven system that acknowledges that OB’s are necessary for more complex cases, and the highest risk even need OB subspecialists in Maternal-Fetal Medicine. We’ve been hoping such population focused analytics and risk tiering will come from DHCS’ Population Health Management “Service” and the new ECM Birth Equity Cohort. Pay also needs to account for ALL perinatal outpatient care (and perhaps well-child care if we’re being lifecourse, dyadic, “no wrong door” care oriented) to limit overpaying for costly hospital care by comparison, which today still incentivizes c-sections over preventive services. So what keeps perinatal and obstetric care from advancing value-based, team-based pay? Is it the lobby of one group over another? Ongoing infighting that makes the teamwork needed, to prove outcomes-based, team-based pay feasible, too difficult? Or perhaps the myopic limitations of our mindsets in healthcare, where we are conditioned to seek just one solution for every problem - pay driven by either outcomes or team members. Not both. No way. Not possible?! 🧐 Would love to hear from all you experts out there on this complicated healthcare financing issue fundamentally still keeping birth equity at bay, regardless of what workforce we promote today or tomorrow. What are the most promising financial reforms ahead in this space and what makes them so special? #maternalhealthequity needs #datadriven #payparity.

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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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The Third Virtual National Health Care Transparency and No Surprises Act Summit ✅ April 16-19, 2024 Part 2 of 2 Aneesh Chopra shared how important it is for consumers to have access to health data, prices, and the resources necessary to understand quality. He also advocated for the standardization of Good Faith Estimates (GFEs) so a hip replacement, for example, would have the same bundled set of billing codes. Ahmed Marmoush, Susan Dentzer and many others shared that you can’t have price transparency without quality as the two must be taken into account in order to understand value. Justin Leader shared a heavy lift taking place in healthcare literacy and expanded on this by saying that consumerism can’t work for people who are unable to make an informed decision. Comments on the Machine Readable Files (MRFs) unearthed several challenges… Christopher Whaley and others talked about the health system Machine Readable Files (MRFs) being less complete, reliable and accurate than the posted MRFs from insurance companies. David Muhlestein in discussion with Niall Brennan shared how the machine readable price transparency files (MRFs) are riddled with ghost codes and other unusable data points. The pair shared the sentiment that price and quality aren’t correlated in healthcare. Kristyn Ulrich of CommonSpirit Health shared that the MRF framework doesn’t appreciate the complexity that occurs on the claim level which is how hospitals are paid. She wasn’t alone in expressing the difficulties that come with evolving and misaligned federal and state requirements. Finally, several people noted that the story is still missing on how all of these developments can turn into actionable impact to help patients at scale.   Additional people who I heard from and hope to continue the conversation with... Joseph Fifer, Francois de Brantes, Niki Panich MD, FCFP, Robert Tennant, Brian Cotter, Joel Ario, Ge Bai, Patricia Kelmar, Katherine Hempstead, Phil LeFevre, Cheryl Matochik, Lauryssa Humm, Peter Schultz, ASA, MAAA, Traci McGinnis, Julie Selesnick, Vanessa Candelora, Alice O'Carroll, POPM, Hemi Tewarson, Katie Martin, Mara McDermott, Doug Jacobs, MD, MPH, Matthew C., Amy Assenmacher, Stephanie Bird, Scott Roth, Howard Kraft, Melissa Speck, Erin Richter Weber, Melanie Wilson, Jamie Cleverley, Vance Ginn, Jeff Wu, continued in comments below.

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