Jim Giordano

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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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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Downside risk for 350K covered members in Pittsburgh including those funded through #MedicareAdvantage, #Medicaid, #ObamaCare exchanges and #Commercial arrangements: #AlleghenyHealthNetwork (the provider) and #Highmark (the insurer) partner for success and show how it's done. Secret Sauce: Invest in #data-sharing tools plus nurturing #collaboration plus attacking the whole system (no baby-steps) plus engaging #patients plus drilling down on #quality. "it’s just another step on a continual journey to high-value, high-quality care. And increasingly, it’s a journey that #insurers and #providers will need to take in tandem as they come together to build a contractual model that doesn’t benefit one party or the other, but the people and communities they serve."

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As Congress reconvenes, the New England Council urges action on three bipartisan priorities: extending telehealth access, revitalizing the Affordable Connectivity Program, and expanding eDelivery for secure financial information. These measures are vital for New England’s economy and quality of life. Read more from my new op-ed:

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2 hospital systems have widely been reported to take these positions: HHC and NYPHS. With the large impact to employer healthcare costs and the push toward transparency, not sure why these stories have not gotten more traction and attention. Plans have also said yes to this. Hopefully this changes moving forward. "HHC purportedly engaged in antitrust violations through their “all-or-nothing” contracts with insurers. A 2021 presentation to the Connecticut legislature’s Insurance and Real Estate Committee defined “all-or-nothing” contracts as contracts that require insurers to include the entirety of a network’s facilities in its coverage plan, regardless of price. Another alleged anticompetitive strategy HHC enacted was the use of “anti-steering” and “anti-tiering” provisions in their contracts with insurers.  According to the Department of Justice, steering is “a method used by insurers to offer consumers options to reduce some of their health care expenses.” Anti-steering provisions prohibit health insurers from including anything that may steer patients to more cost-effective hospitals and facilities. According to the National Academy for State Health Policy, a nonprofit dedicated to analyzing national health policy, tiered networks are when insurers “place providers into tiers based on price and quality and then offer patients financial incentives, typically through lower cost-sharing, to choose providers from a higher-value tier.” Under anti-tiering provisions, insurers are barred from offering tiered networks to patients, which encourage patients to pursue more affordable care.  The lawsuit goes on to say that HHC’s conduct has “forced patients and employers in Connecticut to pay higher prices for routine services that are often available at other hospitals only minutes away for substantially less.”

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Upcoming complimentary webinar for American College of Healthcare Executives members "Winning Together: Navigating Payer Partnerships for a Sustainable Financial Future" August 13, 2024 11 a.m.–12 p.m. Central time offering 1 ACHE Qualifying Education credit The Connecticut Association of Healthcare Executives (CTAHE) Successful healthcare provider executives demonstrate a high level of proficiency and success in leading payer negotiations, forging strong relationships with payers that ultimately translate to improved patient outcomes for populations served. Unlike in a fee-for-service model, payer contract negotiations in a value-based care model are not a zero-sum game. Incentive misalignments and competing stakeholder priorities are not sustainable in an environment where all stakeholders aim to lower the total cost of care and enhance patient health outcomes. In a collaborative model, building successful partnerships with payers is essential, with all entities at the table as equal partners making joint decisions, performing clinical integration activities and working together on programs to support improved patient outcomes and quality performance. This webinar session aims to equip healthcare providers with the knowledge and skills necessary to successfully engage in value-based care models through collaborative relationships with payers. Attendees will gain a deep understanding of the payer perspective, learning to "think like a payer" by exploring the principles and objectives driving value-based care initiatives. The session will cover the internal competencies required for providers to effectively participate in these models and will provide practical guidance on negotiating and executing value-based contracts. Emphasis will be placed on how to forge strong, meaningful partnerships with payers, overcoming traditional biases and assumptions to build win-win collaborations that improve patient outcomes and reduce health disparities. Learning Objectives: Understand the payer perspective on value-based models, including the key principles, internal competencies needed and alignment strategies for successful engagement. Develop a “payvider” skillset to negotiate and execute collaborative relationships with payers, focusing on value-based care contracts, effective negotiation strategies and sustainable practice transformation. Faculty: Rick Goddard, Vice President, Head of Commercialization and Strategy, Lumeris Jeff Anderson, Vice President, Managed Care, Lifepoint Health ACHE Qualifying Education Credit  This activity is eligible for 1 ACHE Qualifying Education credit toward earning or maintaining your FACHE credential.  Credits must be self-reported at My ACHE upon completion of this activity.  https://lnkd.in/e4AS7XKZ

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Healthcare consumes nearly 20% of our GDP and annual trend increases regularly outpace inflation. The trajectory isn’t stopping and for most employers the pace is unsustainable. Many employers looking to embrace their CAA fiduciary duties are finally looking at what they’re paying for services and discovering two big areas of their spend, pharmacy and hospital charges as focal points. Simply stated, How do I get control over pharmacy including PBM and Medical pharmacy and how do I reduce and change the trajectory of hospital costs? For many states, as explained in this article, the biggest health policy initiative to help employers and others with healthcare costs is the Cost Growth Benchmark initiative, which purportedly makes the providers of healthcare responsible for healthcare costs. States claim to examine healthcare expenditures collected from employers and others and then try to attribute those costs to specific entities. So, instead of focusing on the very specific categories of cost that vex most plans; this macro focused benchmarking attempts to hold providers responsible for overall increases in cost. To a hammer, everything looks like a nail. The imprecision in focus has not changed anything. Massachusetts was one of the first to use the benchmark as a tool to control costs and increases and to hold delivery responsible. CGBM has been a failure. In MA, cost increases were nearly double the set benchmark and its clear that health systems have ignored the initiative. Last week the MA Health Policy Commission published a report reflecting collected employer and payer data on pharmacy costs and the data was astonishing. Previous data has shown that hospital costs increases were multiples of the benchmark. How will providers and payers change their behavior? They won’t and haven’t. What kinds of health policy initiatives will actually help employers to reduce costs? (1) Policy and CON initiatives that encourage the creation of ambulatory infrastructure that give definitive free standing access to surgery, infusion and other outside of the hospital services that dramatically decrease the cost of care and increase quality. (2) Policy that requires health plans and service providers furnish detailed and transparent information around their PBM pricing including rebates and POS rebate use along with discounting on brand name drugs. The same transparency should exist for employers relative to mark ups on med pharmacy and the total costs including facility fees. (3) Policy and funding at the state level for more robust All Payer’s Claims Databases that actually encourage employer data contributions and give employers the opportunity to search the APCD for actionable information on cost and quality. Health policy should encourage a marketplace to incentivize payment reform, care transformation and the actual ‘things’ that employers need now. #healthpolicy #healthcare #healthleadership #pharmacy

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❓What happens to healthcare when the government fixes prices for a private business? I think we’re about to find out. Watch Closely 👀 🚨Massachusetts will start requiring urgent cares to accept all patients, even if out of network, to offload the overburdened Emergency Department (thanks to the collapse of Stewart Healthcare - another story) While I have my gripes about the urgent care model, especially when it’s used to replace primary care, one of the things that allows it to work better and be more efficient, is the pricing structure. Urgent care can turn patients away based on inability to pay or require payment upfront for services. This allows them to control their revenue to match the service they deliver. A healthcare business needs to be able to make enough money to pay for adequate staffing in order to give a quality experience. If an external body is setting the pricing structure, this could be a recipe for insolvency. Massachusetts will pay urgent cares at 135% of the Medicare rate. This is much lower than what most commercial plans will reimburse for urgent care fees. The urgent cares will NOT be able to balance bill (I.e. they cannot collect any additional payments to cover what insurance refuses to cover)📉 ⚕️Urgent care has been a reasonable back up for our failed healthcare system. If we start forcing urgent, cares to operate like the rest of the failed healthcare system, I see them collapsing pretty quickly. Let’s be vigilant.👀 Thank you Dr David Weinstock for sharing this important article. Please share your thoughts and predictions on what’s going to happen. #urgentcare #healthcarereform #healthcareshortages https://lnkd.in/eaTXrhJ9

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An Outpatient Clinical Documentation Improvement (CDI) program offers substantial advantages to healthcare organizations by elevating patient care and operational efficiency. By integrating risk stratification with chronic conditions, enhancing quality measures, addressing social determinants of health, and establishing a collaborative team empowered by technology, such strategic initiatives result in improved patient outcomes and streamlined operations.

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Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

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😳Humana faces a significant challenge following the release of preliminary 2025 Medicare Advantage (MA) Star Ratings data from CMS. Only 25% of its MA members are now enrolled in plans rated 4 stars or higher, a steep decline from 94% in 2024. 👉🏻The drop was driven primarily by the performance of contract H5216, which covers nearly half of Humana’s MA members, including over 90% of its Group MA plans, and saw its rating fall from 4.5 to 3.5 stars. 💴This will impact quality bonus payments in 2026. Humana is actively appealing some results and working to improve operating discipline to regain its industry-leading position. 🧘Key initiatives will focus on member engagement, customer experience, and technology enhancements to drive long-term value. Medicare Advantage open enrollment kicks off 10/15 and goes until 12/7. STAR ratings expected to be released to the public around 10/10! 📉Down 22% in premarket! https://lnkd.in/gUTT84tR

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Now that New York has officially been accepted to cohort three of the AHEAD program the twelve hospitals in downstate New York required to engage at a minimum in Medicaid global budget have only a bit over two years to: 1. Stand up a clinically integrated network 2. Aggregate and:or hire a large primary care base and align high performing specialists 3.. Apply for and launch a MSSP ACO 4. Stand up a population health management infrastrucure and care model capable of powering success in both global budget and global risk 5. Develop win-win value based payment contractual, operational, clinical and referral workflows with select high performing community led IPAs/CINs/ACOs As Mr Brault says below, the clock is ticking.

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715 pages of potential regulation. I bet everyone is dying to read this over the thanksgiving break. Here are two things I will be looking into a bit more. 1) Prior Authorization - CMS says, "CMS remains concerned about barriers accessing care and high burden on the system. For example, data reported to CMS by MA plans indicate that, on average, MA plans overturn 80% of their decisions to deny claims when those claims are appealed to the plan. These data also show that a low percentage of denied claims are appealed, meaning many more could potentially be overturned by the plan if they were appealed." I anticipate this to be a hot topic in 2025. As MA plans see margin pressures from utilization and the V28 model shift they will look to ways to control costs. One way to do this is to curb or slow utilization. CMS has voiced a concern but providers have as well. What I find fascinating is that there is a low level of prior auth appeals but a high overturn rate. To me that means either organizations know when something shouldn't have been requested so they give up or they simply give up based on the administrative burden. Alternatively, the high overturn rate tells me there is likely some unnecessary authorization hurdles to jump through. For costs to be controlled providers and payers need to come together to drive meaningful change. 2) Guardrails for Artificial Intelligence- The summary says "given the growing use of AI within the health care sector, such as, but not limited to, AI-based patient care decision-support tools, we believe it is necessary to ensure that the use of AI does not result in inequitable treatment, bias, or both, within the healthcare system, and instead is used to promote equitable access to care and person-centered care for all enrollees." This to me is going to be fascinating to watch unfold. I am a huge believer in what technology can do. I see a world where people can be empowered to achieve greater things by automating simple, repeatable, or low value tasks. We also place a premium on human capital and this frees up time. However we have also seen cases where AI has negatively impacted the industry- be it in denials, gross over capture of risk conditions, or the recent OIG publication about emergency department billing. There are a few other important items that I will be digging into. I want to look into the weight loss medication updates, the possible changes to medical loss ratio calculations for MSSPs, and overall access to care provisions. What jumps out to you? Anyone want to share their deep dive on a particular piece of the proposed regulation? https://lnkd.in/eVjKjzyw

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For 11 consecutive years, reports like this one have found that the prices providers (hospitals, physicians, etc.) charge are the main factor driving Massachusetts’ high health care costs. While we value our hospitals and our health care institutions, it’s worth asking – what are we as taxpayers paying for, and at what cost? Individuals on Medicaid (taxpayer-funded) pay minimal to zero costs (~1/3 of the state’s population) and Medicare (taxpayer-funded) cost share is graduated based on income. But, for people with private health insurance (employer-sponsored health insurance, like Wellpoint members) health care premiums and out-of-pocket costs are taking up a significant –and growing– part of their income- between 20% to 40%. Perhaps it’s time to re-evaluate how taxpayer funds are being used to support health care and work with policymakers to reform reimbursements as means to help people stay healthy and out of hospitals.  In the meantime, below are some steps people can take to start understanding health care costs and stay healthy:   1. Think health, not sick care: eat healthy, exercise regularly, and stay active every day; 2. Take control of your health. Partner with your primary care team and be sure to get recommended preventive care and screenings; 3. Use primary care, urgent care, and community health centers for non-emergent care. These locations are the lower cost alternatives; 4. Understand how using hospitals and emergency rooms for primary care and routine services affects your premiums and out-of-pocket costs. #healthnotsickcare #health #wellbeing #finance #healthcare #value #employer #insurance #healthinsurance #affordability #transparency #incentiveswork https://lnkd.in/dV9SMPFU  

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ICYMI! Our latest #MassDataGov industry updates cover critical topics in healthcare policy and innovation: 🔹 Denny Brennan, MHDC's Executive Director, shares his insights on the use of standardized forms for #PriorAuthorization in Massachusetts, reviewing the impact of a new state law affecting long-term care. 🔹 Janice Karin, MHDC's Director of Policy, Technology, and Innovation, gives a quick overview of the newly finalized #MentalHealthParity rule, explaining its implications for providers and patients alike. 🔹 Interested in #QualityMeasures? Janice also points out a free Centers for Medicare & Medicaid Services course focused on post-acute care measures—great for anyone interested in improving healthcare outcomes! Watch/listen to the full update: https://ow.ly/EHmR50Tlwsk

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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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The Commonwealth Fund’s 2024 report claims the United States is “in a class by itself,” spending the most GDP (16.5%) on #healthcare yet achieving the lowest performance ratings among its high-income counterparts. When analyzed for #AccessToCare, care process, administrative efficiencies, equity and health outcomes, the U.S. comes in almost exclusively last place among other high-income countries. The category the U.S. ranked highest in was care process such as prevention, safety and patient engagement which ranked second out of 10. This might be attributed to programs like #Medicare with #ValueBasedCare models which encourage preventive care and patient engagement. I’ve previously called out how Americans pay nearly three times higher for prescription medications than other high-income countries but from these findings, it’s clear that access to medication is not the only place our system would benefit from innovation and transformation. While we continue to invest in improving healthcare, we still haven’t found solutions that support both patients and providers and improve our performance when compared to peer countries. Read the full report here (https://lnkd.in/eTeksDc2) and let me know in the comments how you think we can improve our performance.

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