Corri Devier

Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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Affordability.  Transparency.  Innovation. PBMs help achieve better health outcomes and lower overall costs.

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Price Transparency in Indiana for 2 Large Health Systems: IU Health & Parkview Focus is ER visits comparing Anthem PPO and UHC PPO contracted rates benchmarking to Medicare Adjusted Rates CPT 99283 Anthem Range % of Medicare: 366%-520% UHC Range % of Medicare: 410%-1,119% CPT 99284 Anthem Range % of Medicare: 639%-794% UHC Range % of Medicare: 631%-1,011% CPT 99285 Anthem Range % of Medicare: 440%-551% UHC Range % of Medicare: 490%-727% Additional Insight: CPT codes 99285, 99284, and 9923 generated $339,301,095 in billed charges through July 2024 YTD for IU Health System All three CPT codes were in the top 13 of utilization and generated the most in billed charges #employeebenefits #pricetransparency

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HOT TIP! 🔥 A fully optimized risk adjustment platform can have a direct impact on the health outcomes of your members. Watch the recording of our webinar to see innovative ways health plans are coordinating risk adjustment functions (like coding and advanced analytics) to identify and treat complex, hard-to-diagnose conditions.  https://lnkd.in/ewc22_5x   #RiskAdjustment #ClarityPlatform #Analytics #HealthTech #HealthOfYourHealthPlan

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Recruitment is a top priority for health systems, but strategic recruiting involves more than just bringing in new providers. It involves identifying gaps in patient access and provider capabilities and aligning recruiting with the health system's overall vision. Read more key insights in this HSG Advisors white paper - "Building an Organization Wide-Recruitment Plan." Society for Health Care Strategy & Market Development (SHSMD) #healthcareconsulting #recruting #medicalrecruiting #healthcareleaders #healthsystem #hospital

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This #EmployeeWellnessMonth, I want to share more about how UnitedHealth Group supports my well-being. From rewards for hitting step goals to mental health resources, you can learn more on our blog: https://bit.ly/4ch0daB

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The first half of this year has seen significant regulatory activity related to Medicare Advantage (MA). Here are some takeaways from the article: 1. Regulatory uncertainties are impacting operational efficiency. 2. CMS is ramping up audits to ensure compliance. 3. Rural providers face additional payment pressures. 4. Prior authorization processes are creating administrative challenges. 5. New rules on AI use in care decisions aim to enhance patient-centric care. https://lnkd.in/ekJpHqqp

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🏥 How are private Medicare plans and vertical integration affecting healthcare? A recent article by Wendell Potter explores the complexities of these trends and their implications for patients and providers. The consolidation of services and the rise of private Medicare plans are reshaping our healthcare landscape, often prioritizing profits over patient care. Here's a quote that got me: "(UnitedHealth Group) now takes in nearly twice as much revenue from the 7.8 million people enrolled in (Medicare Advantage) as it does from the 29.6 million enrolled in its commercial insurance plans in the United States." It's essential to understand these developments and their potential impacts to ensure that patient care remains the top priority. 🔍 Read the full article below. 👉 What are your thoughts on private Medicare plans and vertical integration? Share your insights below! #Healthcare #HealthRosetta #Medicare #VerticalIntegration #PatientCare #Transparency

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If you have Locum operations in Indiana, or Hospitals/Physicians - be aware, the PCF costs are increasing as of 7/1/24: The 2024-2025 annual surcharge rates that physicians and hospitals must pay into the Indiana Patient’s Compensation Fund (PCF) to be qualified under Indiana’s Medical Malpractice Act (MMA) will increase from the current rates, the Indiana Department of Insurance (IDOI) announced Feb. 13. For medical malpractice policies written or renewed on or after July 1, 2024, the following will apply: For physicians, the overall surcharge will increase by 4.2% from the current rates. For hospitals, the overall surcharge will increase by 2% from the current rates. The PCF is a dedicated fund administered by the IDOI and was created in 1975 by the Indiana General Assembly as a component of the Indiana MMA. If a patient is determined or agreed to be entitled to a recovery for medical malpractice, they recover first from the defendant health care provider(s) up to their liability limits, and then any additional recovery comes from the PCF, up to the total recovery limit.  

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The Centers for Medicare & Medicaid Services (CMS) confirmed that personal data for nearly 1 million Wisconsin Medicare beneficiaries was compromised due to a MOVEit vulnerability, first exploited in May 2023.    Here’s what you need to know: ■ Delay in detection: Despite patching the MOVEit vulnerability in June 2023, an additional review in 2024 revealed unauthorized access before the patch was applied. ■ Massive impact: Over 946,000 people are being notified, and CMS is offering free credit monitoring services for those affected. ■ Wider implications: The MOVEit breach is considered one of the largest data breaches, affecting thousands of organizations globally.   For IT professionals managing critical systems, this incident highlights the importance of continuous monitoring and re-evaluating cybersecurity measures after initial threats are addressed.   Link to full article: https://lnkd.in/eDw3MDU6 #CyberSecurityNews #CyberSecurity #SecurityNews #InfoSec #DataBreach #Medicare

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🎉 Big News for Medicare Enrollees! 🎉 Effective July 1, 2024, CMS (Centers for Medicare & Medicaid Services) is significantly reducing coinsurance rates for 64 essential drugs, benefiting over 750,000 Medicare beneficiaries. 💊 This change is part of the H.R. 812 Inflation Reduction Act, ensuring drug companies provide rebates if they hike prices faster than inflation. 💸 This initiative is a huge win for patients dealing with conditions like osteoporosis, cancer, and infections, promising significant cost savings! Starting April 1, 2023, you might have noticed lower out-of-pocket costs for certain Part B medications. 🏥 For those with high drug costs under Medicare Part D, a relief is in sight too! By 2025, no Medicare Part D beneficiary will pay more than $2,000 annually for prescription costs. 🚀 These changes are part of a broader CMS effort to make healthcare more accessible and affordable for all. Stay informed with the latest ASP (Average Sales Price) public files released quarterly. CMS is committed to transparency, ensuring the new coinsurance adjustments and impacted drugs are up to date. 🕵️‍♂️ This initiative marks a significant step towards reducing healthcare costs and improving the quality of life for many. #Medicare #HealthcareSavings #CMSInitiatives FloodGate Medical

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Maximize your staffing budget without compromising on quality. Oppvia's direct hire model delivers top talent while offering significant financial value. Learn more about our cost-effective approach. #StaffingSolutions #ValueInHealthcare

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Affordability for prescription drugs is important and part of improving and maintaining overall health.

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