Dan Keller

The June 2024 MACPAC report is now available (bit.ly/3REu3xN). Here's what it says about Dual Eligible Integration. #Medicaid #Medicare #DualEligible #HealthcareIntegration #DSNP #SMAC #CareCoordination #HealthEquity #DataSharing #QualityImprovement #HealthcarePolicy

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This is a common question I receive when speaking with Medicare payers. When it comes to routine vision coverage, what is the difference between Full Service versus Exam + Allowance coverage offerings? Please check out VSP's blog on this question. The blog not only clarifies the coverage differences, but how it impacts a member experience. https://lnkd.in/g6URCYHc

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Im sitting in the airport on my way back home from a whirlwind of a week and reflecting more on this care management paper series. One additional takeaway that i want to add from paper 4 is that many programs and interventions may promise significant savings based on clinical research or a focus group. While these results may be valid, it’s important to consider that there are decreasing marginal returns as you expand a program to a larger population. It’s critical to understand at what point expanding the program is no longer providing the desired returns. This is something that Wakely can help with. Check out our care management practice page or reach out to me with questions - https://lnkd.in/eqkUFkeA #Wakely #CareManagement

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Now, there is lots in healthcare that defies logic and convention. Usually a shortage of something results in higher value/payments. Good primary care is so essential, and why are we doing this? #thinkingdifferently #cfoinsights #ceoinsights #hr #hrbenefits #employee experience #ESOPCG

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In today's rapidly evolving healthcare landscape, staying ahead of the curve is crucial for managing employee health benefits effectively – and tools like clinical informatics are revolutionizing the way organizations approach health plan management. Our recent webinar dives into proactively managing and optimizing healthcare plans. Check out the webinar replay now: https://ow.ly/HQAn50RCmei #ClinicalInformatics #EmployeeBenefits #BenefitsPlan

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In today's rapidly evolving healthcare landscape, staying ahead of the curve is crucial for managing employee health benefits effectively – and tools like clinical informatics are revolutionizing the way organizations approach health plan management. Our recent webinar dives into proactively managing and optimizing healthcare plans. Check out the webinar replay now: https://ow.ly/PikC50RCOqP #ClinicalInformatics #EmployeeBenefits #BenefitsPlan

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Use case on cost variability within the LA market. Below is the Average PPO Rate for an MRI of your low back. This is comparing 7 LA hospitals contracted/allowed amount average PPO rates across Aetna, Anthem, Cigna, and UHC with Medicare as the benchmark. Huge variances over Medicare and displays why employers need to gain access to this information and take action to steer members away from hospitals that are not a fair market price. Unfortunately, LA is not a unique city as there is cost and quality variability by facility, by provider, by procedure code across all states and all networks. Good news is that there are proven solutions to reduce cost, improve quality of care, decrease or eliminate members out-of-pocket cost, and enhance benefit offerings. If you do what you’ve always done, you’ll get what you’ve always gotten.

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Price transparency MRF callout to be aware of. In the files, you could see for inpatient services MS-DRG's and/or APR-DRG's. These are different billing methodologies to be aware of when comparing network rates by NPI. See breakdown below. Diagnosis Related Groups (DRGs) are a patient classification system that relates the type of patients a hospital treats with the costs incurred by the care. Medicare Severity-Diagnosis Related Groups (MS-DRGs) classify a Medicare patient’s hospital stay into various groups to facilitate payment. These are typically used on the commercial side as well for inpatient services.   APR-DRGs are more comprehensive and include four levels of severity of illness or risk of mortality for each case. These are used on the commercial insurance side if MS-DRG are not chosen. Similar to MS-DRGs, an APR-DRG payment is calculated using an assigned numerical weight that is multiplied by an individual fixed dollar amount. APR-DRGs, however, consider severity of illness and risk of mortality instead of only a complication or comorbidity. More than one significant diagnosis, procedures, age, discharge disposition, and sex can add to the APR’s clinical severity. There are four levels of severity of illness or risk of mortality are: minor, moderate, major or severe.   APR-DRGs and MS-DRGs are both systems of classifying hospital cases based on diagnosis and procedure, and expand upon the basic DRG list by Medicare. #pricetransparency #employeebenefits #costcontainment

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With the struggles that many health plans are facing in Medicare Advantage, understanding care management and where the best place to focus resources and hit the gas is of utmost importance. With that in mind, I'll be brushing up on this oldie but goodie from the SOA in the early 2000s and will be sharing my thoughts as I go. https://lnkd.in/eZWnVS8q #Medicare #CareManagement #Wakely

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Yesterday I shared some initial thoughts on the 2023 risk adjustment transfer report. The headlines tend to focus on the big dollar amounts, but looking at the transfer on a per member, per month basis tells you a lot more. Today, I'm going to explore some of the year over year changes. A few things stood out to me: 1) Florida Blue's transfer is massive, no doubt about it. But it's remarkably consistent year over year - in 2022, their transfer was $110 PMPM, and in 2023, the transfer was $116 PMPM. They have a pretty stable membership block that's fairly high risk. FL Blue is also one of the few carriers in the FFM to offer a platinum plan. A few other carriers show a pretty consistent PMPM transfer: HCSC (BCBS IL,TX, MT, NM, and OK) had around a $100 PMPM transfer both years, Kaiser with about a $45 PMPM payable both years, United with about a $100 PMPM payable both years. 2) Ambetter (Centene) had a fairly sizable shift: in 2022, they received an aggregate transfer of $25 PMPM, whereas in 2023, their transfer was basically $0. Their market share also increased from 13.5% of the entire ACA block to 20% (by far the largest ACA carrier). It makes sense that their transfer would have gotten smaller - with such a large market share, their membership starts to set the standard for what the average risk is. This plays out at the state level, too: in Georgia, their market share declined from almost 50% in 2022 to about 40% in 2023, and their receivable increased from $77 PMPM to $117 PMPM. In Florida, by contrast, their market share increased from 11% to 13%, and their receivable decreased from $27 PMPM to $17 PMPM. As a carrier's market share increases, their receivable / payable is likely to get closer to $0, since a larger market share means their risk is going to be a bigger component in determining the statewide average. 3) I've been a long time Oscar skeptic, but they may finally be hitting their stride. They buck the trend discussed above - their market share decreased in 2023, but their PMPM payable came down from $117 PMPM to $89 PMPM. (Full disclosure: my wife is an employee at Oscar, but she doesn't share anything with me about them and these observations are strictly from the publicly available data below. Neither she nor I have any equity in Oscar... in fact, I shorted them at their IPO but have since closed out that position). I'll share more over the coming days, but does anything stand out to you? Tomorrow I'll look at how Friday and Bright's market exit may have affected the market. If you found this insightful and want to explore your own ACA strategy, Evensun can help. Reach out to me. Fair warning: be prepared for at least an hour or two of free consulting time consisting of me excitedly talking about risk adjustment and ACA strategy! People tell me it's a flawed business model but I can't help myself... https://lnkd.in/g6kmvt4X

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The new ACO PC Flex program offers some potentially substantial financial upsides for MSSP ACOs. We discuss five key takeaways in a new paper: https://lnkd.in/gQeeJY8X

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America's shortage of primary physicians persists, resulting in worsening health outcomes across age cohorts. California recently made a bold statement by setting new benchmarks that support increased investment in primary care, and improve health outcomes. “Investing in primary care works: Research finds that when states invest more in primary care, their residents have better health outcomes and fewer visits to emergency departments and hospital admissions,” said HCAI Director Elizabeth Landsberg. “These benchmarks will make California a national leader in primary care investment, which is key to building a high quality, equitable health system and controlling costs.”  This is big news for those in the health care and insurance sectors. Improved primary care translates to improved access, better health, and ultimately, lower costs. #HealthCareAccess #BackToWork #PrimaryCare #CAPavingTheWay https://lnkd.in/eXBUcUKV

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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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Recently invited to share information on how provider contract discussions are approached. These conversations are generally kept private because we almost always reach an agreement, and we don’t want to cause unnecessary stress or confusion for our members. Please take a moment to view the video and review our latest provider contract updates at https://bit.ly/3XnkxRE

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Ozempic for less than $250? Medicare Plan Finder is live with 2025 plans and many beneficiaries are seeing screens like this one, showing they owe no cost sharing after July even though they won't have paid anywhere near the $2,000 MOOP. This is possible (and common) due to the IRA's "greater of" cost sharing accumulation. Read more about it here: https://lnkd.in/eZ76nU64

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The Inflation Reduction Act introduced several changes to Medicare Part D starting in 2025, emphasizing federal negotiation of prescription drug prices and requiring drug manufacturers to pay rebates, while adjustments to Part D out-of-pocket maximums and creditable coverage determinations are expected to impact employer-sponsored plans significantly. Learn more: https://ow.ly/Rnis50Rso28

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Revenue cycle automation plans include autonomous coding and claims management tech, but cost and resource management are major barriers to adoption, KLAS reports. #revenuecycle

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