Dr. John Grossomanides

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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Vertical integration in the health insurance industry pledges to streamline operations, yet when it comes to drug costs, the outcomes warrant closer scrutiny. The reality is third-party payers may not be capitalizing on potential savings. Major PBMs tout cost reduction and streamlined care; however, the opacity of pricing models raises questions. A candid discussion is essential on the real impact these integrations have on drug affordability, not just for consumers but for employers as well. #DrugCostTransparency #PharmacyBenefits #HealthcareEconomics

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As PBM’s continue to grow in control of our pharmacy needs, the resources – independent retail pharmacies – continue to shrink in numbers. An article titled, “Prescription for trouble: Pennsylvania pharmacists say PBMs are driving pharmacy closures,” written by Ian Karbal, is another example of what has motivated us to collaborate with forward-thinking employers, pharmacies and medical providers to find ways to bypass middlemen control and interferences by working directly with each other. This article cites the problems faced by independent pharmacies that are described by Bob Schreiber, a pharmacy owner in Pennsylvania. He says that he believes that PBMs are “squarely responsible.” The article mentions that some pharmacies “are finding creative ways around PBMs.” We offer one of those creative ways: Working directly with local employers and bypass the PBMs. We are collaborating with independent pharmacies in doing this very thing now. In order to do this, an employer group has to be shown that there are insurance resources and methods that allow the group to control their claims fund reserve and effect these arrangements directly. Whenever this is done, everybody wins. The pharmacy’s margins go up while the group’s costs go down. The biggest barrier that we encounter is just getting people to let us show them how to do this and why it is important for them to do this. Few employers have any idea as to how much pharmacies are underpaid and how much their plans are overcharged. Few, if any, group involve local pharmacy professionals in their year to year benefit cost evaluations. In our view, local independent pharmacies should become more pro-active in bringing this information to the decisionmakers responsible for health insurance choices for their group.   We are very pro-active in this collaboration that has helped bring this about. We recently accomplished this for a medium size group in Illinois, and one in Indiana. We connected them directly with the independent pharmacies in their areas. Their costs have gone down immediately, and the control of their program has shifted to them and the expertise of the local pharmacies. Let us show you how. The Ecchic Group 314-997-8865 www.ecchic.com 11704 Lackland Industrial Drive St. Louis, MO 63146   Article: https://lnkd.in/e9SjaFpq

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"CVS Health blamed the declines on higher usage and more costly claims related to its Medicare Advantage policies." More dominos falling... It's simple math Hospital costs keep accelerating Utilization due to sickness keeps increasing Yet rimbursement via government programs is going DOWN! This is business 101 And you don't need a crystal ball to see what's coming... #Healthcare #business #hr #benefits #ceo #insurance #Medicare

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"Overall, KFF analysis shows that the market for Part D coverage remains robust based on the overall number of plan options, but the number of sponsors, plans, and enrollees in the stand-alone PDP market has trended downward over time, while the MA-PD market remains stable and continues to experience steady enrollment growth." Benistar Administrative Services, Inc. Worldwide Employee Benefits Network NABIP BenefitsPRO Employee Benefit News SHRM State and Local Government Benefits Association Government Finance Officers Association (GFOA) AHIP National PELRA Self-Insurance Institute of America American Benefits Council National Native American Human Resources Association (NNAHRA) New England Employee Benefits Council (NEEBC) George Kaiser Family Foundation KFF U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services International Foundation of Employee Benefit Plans (IFEBP) The Council of Insurance Agents & Brokers National Labor and Management Conference AGRiP (Association of Governmental Risk Pools) Illinois Municipal League ASCEND Agency Growth & Leadership Summit Midwest Coalition of Labor Kelly Loussedes Eli Tate #medicare #medicareadvantage #retirementgoal #groupbenefits #retirementplan #retireemedicalbenefits #benistar #retireegroupbenefits #medicaresupplement #egwp #seniors #retiree

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Great perspective about the complex system we find ourselves in today.

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Value based care is a scam. The clinical consequence’s of Humana’s (and every other Health insurer in the USA’s) value based care including prior authorization rationing of physician recommended care, limited physician and hospital panels to diminish Humana’s labor costs and and diminished labor (physician) and overhead reimbursement (hospital, outpatient, ASC) are clearly evidenced here.

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2026 Medicare Part D negotiated drug list with prices is finally released. I wonder what this will do for Part D pricing in 2026 since 2025 is such a mess. Here's the CMS fact sheet: https://lnkd.in/eg4whr3z

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Interesting developments…

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📈 CMS Disburses $10.3B in Risk Adjustment Payments for 2023 📉 The announcement of these risk adjustment payments for 2023 underscores the crucial role in maintaining stability and fairness within our insurance markets. 🎯 Highlights: ➖ Total Payment: $10.3 billion in risk adjustment payments. ➖ Purpose: To help insurers manage the financial risks of covering individuals with varying health statuses. ➖ Impact: A crucial mechanism to balance out costs across insurers, ensuring equitable access to care and preventing market destabilization. 💡 Why It Matters: For insurers, this means greater financial stability and the ability to focus on patient care without the heavy burden of risk-related uncertainties. For consumers, it ensures continued access to diverse and reliable insurance options. #Healthcare #CMS #HealthPolicy #Medicare #Medicaid

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The need for interchangeability designation from the FDA for biosimilars is hurting the uptake of biosimilars in the pharmacy benefit space. It shouldn't, prescribers can write for other agents, but it does. Now of course PBM decisions and Humira on parity isn't helping either, but ... Recently multiple agents were designated as interchangeable for different strengths, which is great, until you read the fine print to understand that these agents are getting exclusivity in the market for this interchangeability until April 2025 😲 🤯 So, multiple biosimilars can be on the market, and essentially be the same product, but only one of them gets the mostly unnecessary interchangeability status at certain concentrations? So who gets it the exclusivity? 💉 Hyrimoz for 80mg/0.8 ml, 20 mg/0.2ml, and 10mg/0.1 ml products 💉 Simlandi for 40mg/0.4ml products (which, reminder, accounts for ~90% of all Humira prescriptions) We need to remove barriers to biosimilar uptake, and this feels like a big step backwards! I haven't seen a lot of news on this exclusivity yet, except for from the always on top of it IPD Analytics! Are you seeing this reported elsewhere? #Pharmacy #Pharmacybenefits #Biosimilars #Humira #adalimumab

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G2211 Add-on Code Reimbursement Policy - Horizon BCBS NJ For Medicare Advantage Products only: • Horizon BCBSNJ shall consider procedure code G2211 eligible when reported with a new and established patient office and outpatient E&M service. • Procedure Code G2211 shall not be considered eligible for reimbursement when the associated office and outpatient E&M visit is reported with Modifier 25. For Commercial Products only: • Horizon BCBSNJ shall not consider procedure code G2211. https://lnkd.in/d4scUW-B. #medicalcoding #ushealthcare #primedsolutions

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Choosing a PBM? Look beyond the spreadsheet! There are 4 factors that truly matter: ✅ Full Disclosure ✅ Fiduciary commitment ✅ Seamless implementation ✅ Exceptional support At DisclosedRx, we embody these principles as The Fully Disclosed PBM®. We put your interests first. https://lnkd.in/gNVZHQde #PBM #HealthcareCosts #FullDisclosure

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https://lnkd.in/ebYWueWw Federal Trade Commission PDF Report - "Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies Interim Staff Report CONCLUSIONS AND AREAS OF ONGOING FOCUS PBMs are at the center of the U.S. pharmaceutical system. However, their outsized influence comes not only from the expansion of their traditional, middlemen administrative services in processing patients’ pharmacy prescription claims, but also from decades of consolidation and vertical integration across the healthcare delivery system. Analysis of the current industry landscape indicates the largest PBMs have come under common ownership with the largest, most dominant health insurers. In addition, these healthcare conglomerates operate some of the largest retail, mail order, and specialty pharmacies in the country, which compete with local independent pharmacies. Given these relationships, PBMs and their affiliated entities may have the incentive and ability to engage in steering a growing share of prescription revenues to their own pharmacies through specialty drug classification, self-preferential pricing, and pharmacy contracting procedures to target and control the business operations of pharmacies. While this Interim Report principally focuses on the impact of these changing market dynamics on the operation and vitality of the nation’s pharmacies, we also share initial evidence about PBM and brand pharmaceutical rebating practices that urgently warrant further scrutiny and potential regulation."

If there was a Mount Rushmore that included the four most important elements required to succeed at #StarRatings, what would be on it? My experience has taught me that one undeniable element that would be present on that mountain would be "robust and collaborative Provider Engagement". If your provider partners are not engaged, everything else is diminished, including your ability as an organization to compete for new members (which is pretty much everything, right?). On May 22nd, I get to join James Zdarko from Novillus and Jessica M. from Rex Wallace Consulting, LLC to discuss best practices for health plans to engage their providers more effectively in #QualityImprovement (including #Stars) and #RiskAdjustment. Please join us and let's talk provider engagement.

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While not quite the bump received after last year’s record inflation, the health savings account limits will still receive an increase for 2025, as determined under Section 223 of the Internal Revenue Code. Learn More:https://ow.ly/tvVQ50RBWmF #HSA #HealthSavingsAccount #FinancialPlanning

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New research from Avalere & the Community Oncology Alliance reveals how deeply embedded #PBMs are in the #340B program – creating troubling opportunities for abuse. We believe #340B should benefit vulnerable patients and safety-net providers, not for-profit middlemen. 

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