Chris Stanley, MD

The New @Clinically Integrated Network of Indiana Launches to Improve Access, Quality, and Affordability of Healthcare Statewide Indianapolis, Indiana – November 19, 2024 – Health centers across the state of Indiana have joined together to transform the delivery and payment of healthcare across the state to improve health equity by launching the Clinically Integrated Network of Indiana (CINI). These health centers will continue to operate as separate organizations but will work collaboratively to improve health outcomes for 350,000 Hoosiers through initiatives using data to drive improvement, establishing evidence-based practices and workflows, and sharing resources to improve efficiencies. Patients of CINI’s health centers will continue to benefit from the services of their current health care provider teams without a change in site, service, or expense. CINI establishes partnerships between key healthcare stakeholders and providers and health insurance plans, such as Anthem, CareSource, Managed Health Services, MDwise and Humana. The network is also actively working with state government agencies to ensure alignment with Indiana’s healthcare priorities and the health needs of our residents. “We believe that our state deserves the delivery of high-value whole-person health care. CINI will allow health centers to provide better care and reduce costs by collectively becoming more accountable for the value of the care they deliver. This collaboration is all about unity in community.”, said Angela Boyer, Chief Executive Officer of CINI. The formation of CINI reflects a growing national movement toward clinically integrated networks that enable providers to work together under shared clinical protocols, quality benchmarks, and value-based models. “Indiana’s new Clinically Integrated Network is a significant step forward for our state. By enabling collaborative partnerships across the healthcare spectrum, we’re moving toward a more sustainable, patient-centered healthcare system,” said Ann Lundy, CEO of Indiana Health Centers, Inc., a participating member and Chair of the CINI’s Board. About the Clinically Integrated Network of Indiana The Clinically Integrated Network of Indiana (CINI) is a network of healthcare providers committed to transforming healthcare in Indiana by fostering collaboration, improving care quality, and reducing costs. By aligning physicians, health systems, and local organizations, CINI aims to create a sustainable and equitable healthcare model that benefits all Hoosiers. CINI is a wholly owned subsidiary of the Indiana Primary Health Care Association. For more information, please contact Angela Boyer, at [email protected].

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New #ManattOnHealth Insight by Julian Polaris and Katie (Rubinger) Platz: A new GAO report investigates #PriorAuthorization practices for children enrolled in #Medicaid #ManagedCare organizations (MCOs). #CMS agrees that some clarification is needed and may consider additional rulemaking or guidance to address these issues. For more, read Manatt’s latest newsletter. 

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MA: The "STAR" of the show. Silly me, given my recent articles on benchmarking and bidding in Medicare Advantage (MA) as well as the recent stargate fiasco that is happening this year, I thought I’d write a brief article that explains the basics around the star ratings. Well, just like those other topics, the details are super complicated and confusing. 2024 Star Ratings represent services provided in 2022, but don’t impact payments until 2025 and the technical notes include words and phrases like “clustering,” “relative distribution” and “Tukey outer fence outlier deletion.” So instead of a superficial overview, I am making the mistake of taking a deep dive into Star Ratings. I apologize in advance for pulling you down this rabbit hole with me. Given the extent of the information, I’m choosing to start off by sharing it in bite sized pieces and will then post the whole thing in its entirety once I’m finished. Let's start off with...Why do we even have Star Ratings? As you know, in Medicare Advantage, private health plans are paid a fixed monthly amount for each of the Medicare beneficiaries that are signed up with their plan. Given the number of options an individual beneficiary may have to choose from, CMS wanted to help them choose the best plan for them and not just incentivize plans to provide high quality care, but to facilitate growth in the best performers. At a high level, the Star Rating system has two impacts: a guide to consumers choosing among MA plans and as a factor in determining MA plan payments. It is important to remember that there is no real quality data for Traditional Medicare, so star ratings only enable comparisons between MA plans and not between MA and Traditional FFS Medicare. #MA #Medicare #Stars #Tukey

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And now for some judiciary action: A panel in Illinois is examining the consolidation of providers and payers, raising questions about competition, pricing, and patient access to care. "Judge Matthew Kennelly will manage a barrage of suits over whether how payers decide what to pay is legal." ... "Consolidation can lead to increased pricing power for payers, potentially impacting reimbursement rates for providers and costs for patients." Health care consolidation poses significant challenges for independent #communityoncology providers, impacting their ability to remain independent, their financial sustainability and more. While mega entities often tout that consolidation leads to improved efficiencies, the evidence is light. But there is plenty of evidence it reduces competition and drives up costs. Read more in the piece by Allison Bell in BenefitsPRO at https://lnkd.in/eeyurTDJ

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KH's most recent Flash Report unveils promising signs of financial performance, with a notable slowing of margin decline. The widening gap between lower and higher performing organizations highlights the focus on long-term investment and innovation in high-performing orgs. Lower performing organizations must focus on enhancing efficiencies and reworking key elements like their operating model and portfolio management. Explore the insights in the report here: [National Hospital Flash Report May 2024 Metrics](https://lnkd.in/ggUcyDPh). For resources to boost performance, visit us at https://lnkd.in/enBa3Tp

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A brief thread on how MLR is often a stat that is juked (h/t to The Wire) in the “value-based” care world. The medical loss ratio (MLR) is a financial metric used in health insurance and managed health care to measure how much of a premium dollar an insurer uses to pay medical claims and quality improvement activities. The MLR is also known as the medical care ratio, medical cost ratio, or medical benefit ratio (cite: Healthcare.Gov). Many so-called value-based care models cite their impact in the form of medical loss ratio improvement. Most innocently assume that such improvement is generated by better medical management (I did when I first started working in the field). While this may be the case in some models—it is importantly to note that another way to improve a medical loss ratio is be increasing revenue capture in the form of coding. Said another way, to improve MLR, one can reduce the numerator or increase the denominator. Therefore, when someone cites a major medical loss ratio improvement—the key question to ask is: did the MLR improve because of true medical utilization reduction or because of better revenue capture? Most will glibly (and sometimes dishonestly) say “both.” At which point it’s important to ask, what fraction of Medical Loss Ratio improvement arose from better medical management and what fraction from better revenue capture. Usually, what we will find is that most dramatic improvements in MLR are a function of improvements in revenue capture—and only marginal improvements in medical cost-management. In that way, the so-called “value” produced by many value-based care models isn’t true value. It’s better revenue capture. And many “value-based” care models have been granted undue recognition for medical cost management—citing filthy MLR improvements—that are associated with minimal true improvement in medical expense. This kind of short-cut taking sets back the whole value-based care movement which (while appropriate revenue capture is necessary) should be about overall better cost management and reducing total cost of care—not better revenue capture alone.

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In 27 states and Washington, D.C., NPs have Full Practice Authority, giving patients direct access to primary care providers. States with FPA consistently rank higher in health outcomes—because when NPs can practice fully, everyone benefits! #NPWeek2024 #FullPracticeAuthority

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The 2025 Home Health Final Payment Rule introduces a new #admissiontoservicepolicy, formalizing processes many home health providers already follow. The policy requires agencies to: 💠 Standardize Admission Criteria: Evaluate patient needs, agency capacity, and staff competencies consistently, with thorough documentation. 💠Publicize Services: Clearly share and regularly update available services, such as advanced wound care or dementia care capabilities. While aimed at improving care access, the policy doesn’t address systemic staffing shortages, which led to 76% of patient referrals being rejected in 2022 (WellSky). Experts from both LeadingAge and the National Alliance for Care at Home worry the rule shifts responsibility to providers without addressing these capacity challenges. #HomeHealthCare #MedicarePolicy #AdmissionToService #PatientCare #HealthcareCompliance #StaffingSolutions #HealthEquity #SeniorCare #HomeHealth #Hospice #HomeCare #HomeHealthFinalPaymentRule #2025 https://lnkd.in/ewHay8gC

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New CMS guidance clarifies Medicaid and CHIP payment policies for pediatric #palliativecare, aiming to improve access and reduce disparities for seriously ill children by expanding early screening, care coordination, and workforce support. https://bit.ly/3Ya3rHu

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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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With a proposed Medicare provider payment rate for 2025 that is below 1994 rates, many online are directing their frustration at Centers for Medicare & Medicaid Services. In reality, much of the challenges with the payment rate are statutory in nature, meaning they are due to laws passed by Congress and out of the control of CMS. Let us hope that Congress recognizes the importance of the Medicare system and realizes that their action is necessary to protect it. Read more here. Thanks to MedPage Today & Genevieve Friedman. https://lnkd.in/gYRrDvVf

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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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For 2025, regulators approved the following average increases for health insurers in the individual market: Blue Cross HMO: 11.56% Health Partners: 9.71% Medica: 1.95% Quartz Health Plan: 9.43% UCare: 8.8% Costs of Medical care continue to increase. As a country we spend so much more on heath care compared to others - If we could spend less on health care more could be spent in other areas that has impact. Education and Social determinatives of heath ( Housing,food,transaportation), defense and economic growth. The cost of health care is having negative effect on our culture. Make it a conversation that says it needs to be addressed.

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The Congressional Budget Office recently released a report on Medicare ACOs. Here's a brief summary mixed with personal comments: ACO types associated with greater savings either a) were led by independent physician groups, b) had a larger proportion of primary care providers or c) had initial baseline spending higher than the regional average. One comment on that last factor I found interesting was that increased expense from post acute care tended to be an area of greater impact: “...postacute care, which includes skilled nursing care and rehabilitation services, is costly and has the potential to be overused or used inefficiently, making it a readily identifiable target for ACOs aiming to decrease spending.” ACOs led by hospitals performed less well because: “If hospitals reduced admissions, then they would earn less revenue to cover their fixed costs, weakening their incentive to generate shared savings.” Something they touched on that I think is a key weakness is that ACO benchmarks are updated over time to reflect the observed spending among that ACO’s attributed beneficiaries. “Because of that structure, ACOs that lower their spending are effectively penalized with lower subsequent benchmarks.” The CBO report also suggested ways to potentially improve the offerings. “Those approaches can be grouped into the following categories: those that would increase providers’ incentives to participate in ACOs, those that would increase providers’ incentives to reduce spending, and those that would increase awareness and engagement of beneficiaries.” One suggestion I called out above is the idea of eliminating “the rebasing of benchmarks using historical spending among an ACO’s beneficiaries and instead use administratively set benchmarks.” I have also found that, due to external impacting factors that occur each year, retrospectively looking at the rate of increase in expenses for the attributed population vs the actual rate of increase for a similar but not attributed population, is a much more fair assessment of the impact of the ACO than a prospectively projected target. Another key issue with ACOs is the lack of patient engagement. It is quite common for patients to a) not know they’re “in” an ACO and b) have no incentives to participate in the ACO’s offerings or services. This article notes “…strategies that rewarded patients for obtaining services from ACO providers could enhance communication and engagement between providers and patients and reduce Medicare spending.” The analysis goes on to say that “Without a clear financial incentive, beneficiaries tend not to obtain care exclusively from ACO providers. One way to strengthen that incentive would be by waiving Part B cost-sharing requirements for beneficiaries who obtain care from their primary care physician or another provider in the ACO.” Full CBO report here: https://lnkd.in/gEUaFZKV

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How are stakeholders integrating the patient perspective into health technology assessments? What are the implications for evidence strategy, health equity, caregiver involvement, and care delivery? A recent panel of #AvalereExperts and external colleagues answers these questions and more: https://lnkd.in/eRmFB-vP Featuring Laura T. Housman, MPH, MBA, DrPH(c), Mina Alsaraf Allo, Shelby Harrington, Nikki Martin, Claire Saxton, and Joey Mattingly #HealthTechnologyAssessment #HTAs #healthequity #patientperspective #patients

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Studies show Medicaid expansion elicits positive effects across a range of categories including social determinants of health, disparities and more: https://lnkd.in/eFcuZY2t. #medicaid #medicaidexpansion

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Off-Cycle SNF Provider Revalidation: Mandatory Form CMS-855A Top 7 Things To Know: 1. Mandatory Revalidation: Starting October 1, 2024, all SNFs must revalidate their Medicare enrollment by the end of the year. This process requires completing an updated CMS provider enrollment form, which now asks for more detailed information than before. 2. Off-Cycle Revalidation: Normally, provider revalidation happens on a regular cycle. However, this "off-cycle" revalidation is a one-time requirement starting this year, impacting 100% of SNFs, regardless of their size or ownership structure. 3. CMS Enrollment Form 855A: The new form, which must be completed by SNFs, is longer (20 pages compared to the previous 14 pages) and includes additional sections about "Additional Disclosable Parties" (ADP). SNFs must provide detailed information about all ADPs that have a significant operational or financial role in the facility. Providers can access the form via the PECOS (Provider Enrollment, Chain, and Ownership System) online platform. ·     Visit the PECOS website: https://lnkd.in/g5kBTqfW ·     Log in using your CMS credentials. ·     Locate the revalidation section. ·     Link to CMS 855A Form: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://lnkd.in/gqAvEnZk 4.    Timeline: ·     CMS will send letters to SNFs starting on October 1, 2024, and through the end of the year. ·     Providers have 90 days to respond after receiving the letter. ·     Failure to complete the revalidation in time could disrupt the facility's ability to bill Medicare.   5.    Additional Disclosable Parties (ADP): This is a key new requirement. An ADP is anyone or any entity that: ·     Has significant operational, financial, or managerial control over the SNF. ·     Owns, leases, or subleases property to the SNF. ·     Provides management, consulting, or financial services to the SNF. This information must be disclosed in the new enrollment form. 6. Importance of Compliance: SNFs must complete this revalidation within the specified timeframe to avoid disruptions in their Medicare billing. Providers are advised to consult legal counsel to ensure they correctly interpret the reporting requirements and avoid errors in their submissions. 7. PECOS System: The information must be submitted through the PECOS system, which is the online system used by CMS for provider enrollment. This process requires more detailed reporting, especially concerning the ownership and operational control of SNFs and the ADPs involved with the facility. Since all SNFs are affected, every provider should be prepared for this and take timely action to prevent any interruption in Medicare billing. Failure to comply could result in significant financial issues for the facility. #SNFCompliance #MedicareRevalidation #CMSUpdates #HealthcareProviders #HealthcareCompliance #CMSFrom855A

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Consider Cleveland Clinic, one of the world’s premiere healthcare providers. After receiving unacceptable evaluations in patient satisfaction and employee engagement in 2008, the Clinic launched a multi-phase initiative to embed Serving Leadership principles into its organizational culture. The results were nothing less than dramatic. When compared to other hospital systems in 2008, Cleveland Clinic ranked only in the 43rd percentile for employee engagement. In 2013, it scored in the 87th percentile—a significant improvement that also had a direct, measurable increase in patient satisfaction. You can do the same: https://buff.ly/3NHKtmL #servingleadership #centerforservingleadership #lead #grow #transform #increase

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