Douglas Dietzman, MBA

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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What is the bottom line if you have financial responsibility for a provider group? Your competitors have the ability to know your contracted rates for everything you do. That's the bad news. The good news is that you can know theirs to help you in your next negotiation.

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Key Strategic Insights = A Successful OP CDI Program The challenge of value-based care starts with a collaborative approach, when launching an Outpatient Clinical Documentation Integrity (OP CDI) program. Here are some key strategic insights to success: 1. Engage with Population Health Understand Pain Points: Begin by understanding the specific challenges faced. This fosters collaboration. Tailored Questions: Use customized questions to facilitate productive discussions and ensure alignment with needs. 2. Effective Software Implementation Manage Patient (Pt.) Volumes: Implement software solutions to efficiently handle pt. volumes. OP CDI Calculator: Utilize a calculator to determine Full-Time Equivalent (FTE) needs. Data Analytics and Reporting: Emphasize the importance of continuous improvement via data analytics. 3. Workflow Creation Establish Robust Workflows: Create strong workflows before integrating reviewers. 4. Collaboration & Communication Promote Strong Collaboration: Encourage robust communication between key stakeholders. Leverage Software: Use technology to reduce physician burnout & streamline communication. 5. Patient-Centered Approach Address social determinants of health (SDOH) & ensure accurate documentation of conditions and care plans. Patient Outcomes: Keep patient care at the center of all doc. & workflow processes. 6. Regulatory Compliance Adhere to Guidelines: Follow regulatory requirements such as CMS guidelines on Hierarchical Condition Categories (HCC) coding to avoid penalties and enhance credibility. 7. Measurable Outcomes Set Clear Goals: Aim for measurable outcomes like improved HCC recapture rates, enhanced RAF scores, better HEDIS measures, and addressing SDOH needs. 8. Stakeholder Engagement Involve All Stakeholders: Ensure that executives, clinicians, and other relevant parties are involved in planning and implementation process. Success Stories Recently, I helped several CDI directors validate their cases for OP CDI programs within Accountable Care Organizations (ACOs). By engaging with population health leadership, we identified key issues such as RAF gaps and HEDIS measures, and tailored processes to address them. For instance, a CDI director I guided successfully identified HCC and HEDIS recapture as their biggest pain points. With strategic solutions in place, they are now ready to implement the project for the 2025 budget yr., aiming to improve their HCC recapture rate by 20%, leveraging data analytics for outcomes and improvement needs. Benefits of Implementing These Strategies Align Risk Stratification: Properly align risk stratification with chronic conditions and healthcare needs. Quality Measures: Improve quality measures and address SDOH. Collaborative Team: Ensure success with a collaborative team supported by technology. Overall, these strategic actions will enhance patient care and operational efficiency. #Healthcare #Leadership #CDI #PatientCare #ValueBasedCare #HealthcareInnovation

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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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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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Very interesting article. It compares hospital and health plan consolidation in specific markets. Indiana is a market that is deemed a high cost market (7th highest in nation for hospital costs) because of hospital consolidation per studies, yet when you look at the market, plans have more leverage as the top 3 represent 91% of the large group market. A few thoughts: 1) you can look at number of hospitals, but it would be better to compare commercial spend for these systems as I would imagine a lot higher than the counts indicate. Some hospitals may have a higher proportion of governmental business and that needs to be considered. 2) Based on plan leverage, one would think plans would say no to continued commercial price increases. It's important though that employers support plans in these discussions. I have seen many times over the years that employers want access above everything else, which means the plan has little leverage with the hospital to take hard line stands or risk losing large national employers who will just switch to another plan creating a vicious cycle of continued cost increases. 3) Under this environment, there is little incentive to move to VBC like arrangements vs. fee for service. 7. For example, in Indiana, the systems with the largest share of total hospitals are St. Louis-based Ascension (13.9%), Indianapolis-based IU Health (11.3%), Mishawaka-based Franciscan Health (8.7%) and Franklin, Tenn.-based Community Health Systems (8.7%). These four systems own 42.6% of all the hospitals in Indiana combined 8. On the other hand, the three largest payers in Indiana — Elevance Health (68.9%), UnitedHealth Group (17.1%) and Physicians Health Plan of Northern Indiana (5.3%) — represent 91.2% of all privately insured patients with insurance from the large-group market.  

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The California Office of Health Care Affordability has recently approved a requirement that all healthcare providers report their annual operating expenses. If those expenses increase more than 3.5% (eventually lowering to 3%) in a year, that provider will be fined, ironically increasing their expenses. The state claims this regulation is aimed at protecting consumers from high healthcare costs. This is the same State of California that recently raised all healthcare workers' minimum wage to $25 per hour (up from $15.50).  For our health system, that results in a $30 million annual cost increase and a 7.5% increase in our salary costs. This is also the same state that passed an unfunded mandate that requires our system to spend about $1 billion to replace a hospital building that they feel is at risk from damage in an earthquake. And it’s also the same state that increased the cap on medical malpractice lawsuits…and has authorized utility companies to raise their rates 15% per year.  So, with all of these unfunded requirements and policies that dramatically increase providers' costs beyond their control, how exactly does the state suggest that we limit our expense growth to 3% per year?  Healthcare cost inflation has already been running at more than 5% before any of these new requirements took effect. Perhaps if California wants to get serious about reducing the cost of healthcare they might look at the managed care plans. The most recent data I could find from the California Health Care Foundation indicates that California managed care companies made $222 billion in 2020. What direct value did these companies provide to the health of our communities? Meanwhile, hospitals and physicians are providing direct patient care and struggling to survive- especially systems like Kaweah Health that serve a high percentage of Medi-Cal (Medicaid) and Medicare patients.  On a side note, the governor did sign a new managed care organization tax into law this year, which was promised to increase Medi-Cal reimbursements to providers, but all signs suggest that he now intends to use those proceeds (nearly $7 billion) to fill holes in his budget's general fund deficit and will not be providing Medi-Cal rate increases. I would humbly suggest that if the state is genuinely concerned about its residents' cost of living, they might look at the state income tax (highest in the country), its gas prices (highest in the country), the essentially unaffordable housing costs, or countless other factors that will have a larger impact on individuals' pockets than beating up healthcare providers with laws that don't make any sense. #hospitals #california #healthcare

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Keep our rurals open but if you really want to help get the foreign equity owned GPO that sets the pricing for our hospitals BANNED from our state. Economies of scale are used by Vizient against Oklahoma rural hospitals. If you have 13 tiers, hidden tiers, and tier maxes…that’s not a contract, that a free for all nightmare of a scam we all fell for. Their awful written tiered agreements force our rurals to pay more for the exact same items that our large hospitals pay less for. Example box of gloves a large hospital system in the state will pay 6-8 bucks for a box of 250 exam gloves. That same box for a rural EMT? 24 bucks. There is no price transparency and you are forcing patients who live in rural areas to pay more because of the lack of infrastructure by the corporations serving them to effectively and economically get goods and services to these hospitals. And distributors who whine about the cost of delivering to rural hospitals all while posting BILLIONS in profit every quarter are the first on my 💩 list. Let’s keep our rurals open but let’s make them more profitable so that they can continue to add much needed services and gainfully employ more community members.

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Will AI and ambient listening replace keyboards in exam rooms? Reid Stephan, VP and CIO at St. Luke's Health System, interviews Dr. Ashis Barad MD, CDIO, and Joseph Seliski, Director of Operations and Strategy, from Allegheny Health Network as they discuss their future predictions within healthcare. Dive into their insights on clinical advancements and the evolving healthcare landscape in this #TownHall: https://loom.ly/IUX_c74 #TWH #HealthIT

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Major Changes Coming For The KC Market 📢 Blue KC to Exit Medicare Advantage Market by 2025 Due to Regulatory Demands 📢 Blue Cross and Blue Shield of Kansas City (Blue KC) has announced its departure from the Medicare Advantage (MA) market by the end of 2024, citing increased regulatory demands and financial pressures as primary reasons for the decision. The company will shift its focus to employer-sponsored health plans, Medicare supplement plans, and Affordable Care Act plans while ensuring uninterrupted, quality service to current MA members through 2024. With a smaller MA membership base, Blue KC finds it challenging to compete economically at scale, leading to the difficult but necessary market exit. In a statement, Blue KC's President and CEO, Erin Stucky, expressed disappointment, saying, “We explored every alternative path for our MA members and are disappointed we must exit this line of business.” This move aligns with industry trends, as other insurers, like Oscar Health, have also exited the MA market due to similar challenges, including the impact of regulatory changes such as the CMS's benchmark payment adjustments on the profitability of MA plans for smaller insurers. #Healthcare #MedicareAdvantage #BlueKC #RegulatoryChallenges #InsuranceIndustry #HealthPlans #CMS #MarketExit

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Appreciate this breakdown on Healthcare Trends in Q4 from an informed source. Agree entirely with how AI is impacting RCM: • Cost Savings: AI reduces the time and manpower required for contract negotiation, claim submission, and payment tracking. • Improved Accuracy: By eliminating manual errors, AI ensures compliance and maximizes reimbursement rates. • Faster Payments: AI expedites claim approvals and denials, improving cash flow for healthcare systems. • Scalability: AI tools allow organizations to handle increased administrative tasks without proportional increases in staff.

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Wisconsin - home to leading healthcare software companies. Wisconsin Based Epic continues to widen its EHR market share lead as reported by Becker's (based upon the May 17 2024 KLAS report) earlier this year. Percentage of hospitals 1. Epic: 39.1% 2. Oracle Health: 23.4% 3. Meditech: 16% Percentage of beds 1. Epic: 51.5% 2. Oracle Health: 23.8% 3. Meditech: 13.4% What's not reported in KLAS is that a similar trend is taking place within IV QMS. An interesting twist; In the IV QMS market, #1 (Pharmacy Stars) and #2 (Pharmacy OneSource) are both based in Wisconsin. Health systems employing Pharmacy Stars' Compounding360 for compounding training and compliance, reported serving more than 70,000,000 patients combined in 2023. Based upon current momentum, Pharmacy Stars expects to surpass 100,000,000 patients served by its customers in 2026. #wisconsin #pharmacystars #compoundingsoftware #compoundingcompliance #compounding360 #IVQMS #USP797

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Dr Jaime Bland DNP, RN-BC leading a great session at the Iowa Healthcare Collaborative Annual Event on Clinical and Claims Data. Some key takeaways: - one person one record: critical for coordination of care - data sharing improves quality measurement and patient safety - an enterprise master person index is critical to matching the right records for the right individual and making that information available to clinicians and care providers

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💡 Unpacking the Myth of Hospital Margins Reading Laura Dyrda's recent article in Becker’s, I've been reflecting on a critical issue that is often misunderstood: the financial health of our hospitals. Despite reports of increased profits and stronger margins for large health systems over the past 18 months, it’s crucial to understand that this doesn’t equate to overflowing coffers for hospitals. As Dr. Craig Kent from UVA Health highlights, the reality is that hospital margins are incredibly thin, if they exist at all. The $4 trillion healthcare industry is often perceived as a goldmine for hospitals, but in truth, much of that revenue flows to pharmaceutical companies, insurers, and other non-provider entities. This misconception can lead to misunderstandings about where resources are actually needed within the healthcare system. Lyndon Edwards from Loma Linda University Medical Center pointed out that rising costs for supplies, pharmaceuticals, and labor are outpacing reimbursement rates. This financial squeeze means that hospitals are constantly juggling to maintain operations and invest in patient care and technology. Particularly concerning are safety-net hospitals, which often operate with negative margins. Factors such as payer mix, insurance rates, and geographic markets lead to significant disparities. Some hospitals struggle to stay afloat while others expand and diversify. As demand for care continues to rise, especially with more complex cases and mental health issues, we need innovative financial models and sustained support to ensure hospitals can continue to serve our communities effectively. #HealthcareFinance #HospitalMargins #HealthcareManagement #FinancialChallenges #SupportOurHospitals What do you think are the biggest financial hurdles hospitals are facing today? Let’s discuss. 👇

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If you build it, will they come? I’ve heard countless organizations - #MA plans, #Medicaid plans, risk-bearing providers, vendors, PBMs, and retail players - say “we need to build the capabilities to XX”. Many are looking to vendors for solutions, but few vendors are ready to invest in new capabilities without contracts.  Anyone else sensing this (problematic) new conundrum? Here’s my quick take and a few ideas to break through this barrier. Many sales meetings are often held with functional departments, and often do not include the #MedicareAdvantage #StarRatings, #RiskAdjustment, #HEDIS, IT or P&L owners. We must collaborate to get those departments’ urgent needs integrated into new vendor purchases in order for new activities to meet new and emerging needs, remembering that: 🌟 Vendors are vital to your success.  🌟 Vendors operate in a more volatile environment than plans. 🌟 Vendors have smaller budgets than plans. 🌟 Vendors need signed contracts to make significant investments.   🌟 Vague RFPs waste vendors’ time and resources. Collaboration creates win-win contracts which expand capabilities of both parties. I encourage plans to: ✅ Ask vendors about their roadmap; including timing and certainty of planned enhancements. ✅ Include the #Stars, Risk Adjustment and #PartD teams in new vendor discussions. ✅ Consider adding a vendor's roadmap capabilities to contracts. ✅ Co-create with trustworthy vendors. I encourage vendors to: ✔ Ask about the customer’s unmet needs. ✔ Offer to co-create solutions to new and emerging needs with willing customers. ✔ Offer to accelerate roadmap capabilities with willing customers.   ✔ Articulate the things you would be willing to do if a customer would be willing to contract for it. This is a #MarketMakingMoment as #CMS has thrown down the gauntlet with #NewNeedsOfStars and #NewNeedsOfMA. This is a stellar time for vendors to review current and planned capabilities with a broader lens on new and emerging MA, #Compliance, Stars, #ECDS, #Interoperability, #HealthEquity, Medicaid & #SNP Aligment, and Risk Adjustment needs. If you need help, reach out to us.  #WhatGotYouHereWontGetYouThere  ⭐ ⭐ ⭐ ⭐ ⭐

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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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NEWS ALERT- CMS has finally released the 2023 MSSP results. The results provide tremendous insight on the ACO landscape, risk adjustment, and value based care. Here are some numbers: Thanks for reading. Help us get the word out by smashing the like button, sharing the post, or commenting. Key stats -453 ACOs with data released -69% of ACOs achieved shared savings -$3.08 billion dollars in shared savings payments to organizations -The top 10 organizations with the most savings racked up $631M, or 20% of all savings. -Average risk score for the top 10 organizations with the largest savings in pure dollars (not adjusted for ACO size) was 1.137 -Average risk score for the top 10 organizations with the largest savings per beneficiary was 1.379 -75% of organizations with a risk score above 1.00 had shared savings. Only 65% of organizations with a risk score below 1.00 had shared savings. -78% of the largest 100 ACOs by size had savings while only 64% of the 100 smallest ACOs had savings. CMS noted "ACOs led by primary care clinicians had significantly higher net per capita savings than ACOs with a smaller proportion of primary care clinicians. These results continue to underscore how important primary care is to the success of the Shared Savings Program." This makes sense because primary care is such a critical driver in overall patient care success and in accurately reflecting risk scores. There is a LOT more to dig into. My main takeaways are: 1) Primary care participation is a driver of success 2) Risk scores are a critical component of success and organizations in risk should have outpatient CDI programs and strong compliance programs 3) Larger organizations may have more resources and infrastructure to build scale for success Let's talk more about this. What do you see in the data? What is your experience with your ACO? https://lnkd.in/erjc-peV

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AMA ADVOCACY 2024 EFFORTS with fixing pre/prior authorization: • Secured a CMS final rule that requires government-regulated health plans to reduce the timeframes for prior authorization decisions and to publicly report program metrics. These plans will also be required to offer electronic prior authorization technology that directly integrates with EHRs. These changes build on new Medicare Advantage requirements that went into effect in January 2024 that ensure validity of prior authorization clinical criteria and protections for care continuity. • Secured reintroduction of H.R. 4968, the GOLD CARD Act of 2023, which permits physicians with a strong record of complying with prior authorization requirements to be exempt from this utilization management technique in Medicare Advantage. • Working in partnership with state medical associations across the country to enact prior authorization reform using AMA model legislation, data, testimony and other resources. Ten new state laws have been enacted in the last year and the AMA is supporting more than a dozen bills currently in state legislatures. • Facilitated United Healthcare and Cigna reducing the volume of their prior authorization requirements by 20% and 25%, respectively. Source: https://lnkd.in/enBueStp #preauthorization #priorauthorization #medicalbilling #practicemanagement #revenuecyclemanagement #EMR #EHR

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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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