John Lee

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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Great commentary and details to be considered from post by Deborah Williams Too few probably understand what you've posted, the other major part of the problem. Commercial insured populations (employers & employees) pay the price for government policy failures that represent major hits on company bottom lines or lead to more individual bankruptcies today. #employeebenefits #employers #commerialinsurance #epcouncil.org

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How's this for connecting the dots in #healthcare?   Imagine being a leader of a health system employing 20,000 people charged with caring for the nation's most densely populated state, a national cybersecurity expert, and a committee member of a GPO responsible for billions in hospital purchasing.   That's Brian Gragnolati.   Brian is President and CEO of New Jersey’s Atlantic Health System. He sits on an advisory committee of the Cybersecurity and Infrastructure Security Agency. And he chairs the executive committee of AllSpire Health Partners.   That’s a lot to type, let alone do.   A few months back I had the opportunity to catch up with Brian, chatting about the latest in healthcare. It got me thinking about his responsibilities and how he achieves so much.   It all comes down to relationships.   Here’s the thing: Strengthening ties between all of healthcare’s stakeholders is the only way we are going to overcome fundamental challenges and better serve communities across America.   That’s because, in this complex industry, every piece needs to fit together to keep operations running like clockwork. That requires intimate collaboration.   Take cybersecurity. We may not think much about back-end systems, but we sure notice when they go down. Remember the faulty CrowdStrike update that crashed computer systems around the world overnight? Banks, airlines, and hospital systems shuddered.   So, if we want to make the most of the technologies that support clinicians, empower health systems, and push this industry forward, we need robust cybersecurity that’s built specifically for healthcare.   And to create that kind of resilience, we need folks who understand this industry inside and out. We need folks like Brian.   Brian knows the rhythms of a hospital at 2 a.m., the flow of supply chains, and, most importantly, the profound responsibility of caring for millions of lives.   Brian is a rare breed. But everyone has the power to build relationships that lead healthcare to a brighter and more connected future.

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🤷‍♀️ Patient Attribution 💡 Managing complex patient attribution requires a combination of advanced data analytics, clear rules, continuous monitoring, and active engagement with both providers and patients. Do you know how and where patient are assigned? Have a great Friday! #valuebasedcare #healthcare #leadership

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Join us for an enlightening session where we delve into the evolving role of pharmacy actuaries. Discover how past and present concerns are shaping the future of pharmacy forecasting and what this means for upcoming pipeline events. View the 2024 SOA Health Meeting agenda here: https://optumin.co/trs63n #SOA #Optum #healthcare #payer #pharmacyactuaries 

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🚨 Top 10 #PatientSafety Concerns for 2024. 📌 Have significant changes been made over the last decade? An important question is to reflect on what has been done, what we are doing, and what remains to be done.

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So, payers use AI to deny claims. The AI they use is not good at what it does. That puts the burden of proof on the doctor and the patient who have to navigate a horrible appeals process. Can you imagine if your doctor used AI instead of actually seeing you? Can you imagine if the AI was as bad as what the payers use and missed obvious things? "Mr. Howrigon. I have good news for you. Our AI system, AutoCare, has diagnosed you. Well, no Mr. Howrigon I didn't actually examine you or even look at any test results. You see, none of that is necessary any more because of our wonderful computer we have. All I have to do is sign the chart and bill your insurance company. What's that? Oh, yes, the good news. Well our system noticed that you haven't had your period and concluded that you are pregnant. Congratulations. What's that you say? You are a man. Huh, I wonder why the computer didn't take that into account? Are you sure you are a man? Can you prove it?" This has to stop at some point. Patients are being harmed, doctors are getting burned out and insurance companies and executives are getting rich!

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The ability to be compensated for work carried out in the healthcare space has become increasingly difficult and complicated. It is imperative that our industry remains current on trends, changes, and projected challenges, to ensure our readiness in combatting them. The ambulance industry of today is far different from when our organization first opened in 2010, and we have continuously evolved to meet these challenges head-on. This will remain a big talking point for years to come, and/or until significant changes are made to the benefit of providers. In healthcare, you expend a great deal of capital to provide a service, and in return, you "hope" for reimbursement. Try doing that at a local restaurant - order and eat your food, and tell the staff you MIGHT come back with payment in 90-120 days. Let's see if you make it out of there without cleaning some dishes on your way...

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Yes, CMS can consider costs in medical policy decisions. Occassionally, you hear a point-blank remark that "Medicare can't consider costs" in policy decisions. Well, yes it can, and often remarks on costs and clinical decisions. There's an example in this week's Final Inpatient Rule for FY2025. CMS writes, "In deciding which treatment is most appropriate for any particular patient, PHYSICIANS are expected to balance the CLINICAL needs of patients with the efficacy and COSTLINESS of particular treatments. We continue to believe that [a type of policy change] would remove consideration of the COSTS of new technology from treatment decisions, and that it is important to maintain some incentive to WEIGH THE COSTS of new technology in making CLINICAL decisions." #cms #costeffectiveness #cost

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#CMS Drop "CMS is providing the attached set of Q&As to document responses to questions we received during the “Use of Encounter Data in Overpayment Reruns” User Group on Wednesday, May 1, 2024." "CMS is providing this set of Q&As to document responses to questions we received during the “Use of Encounter Data in Overpayment Reruns” User Group on Wednesday, May 1, 2024. Additionally, all scenarios discussed during the User Group have now been posted to the CSSC Operations website, along with the slide deck from the User Group. The details discussed regarding the scenarios reviewed during the User Group call can be found in the “Description” column of each scenario. If there are additional questions after reviewing the Q&As below and the scenarios posted to the CSSC Operations website, please email [email protected] and specify “HPMS memo – Follow Up to May 1, 2024 ‘Use of Encounter Data in Overpayment Reruns’ User Group” in the subject line."

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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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If you want to study Network Effect in Healthcare, study the rise of Epic EHR! 2012: Epic's market share was 20.6% of beds.  2021: Epic's market share increased to 46.5% of beds.  2022: Epic's market share increased to 35.9% of hospitals and 47.6% of beds.  2023: Epic's market share increased to 39.1% of acute care hospitals, and Epic was the only EHR vendor to see a net market share increase. The following article from Harvard Business School (2015) highlights Epic EHR's success. 1. First there is an inciting event such as government regulation i.e. Regulatory Capture( HITECH Act in 2009). 2. Switching Cost- Once implemented, switching costs are too high to move to another vendor due to the cost of implementation, time spent, productivity lost, and changing behavior. Anyone involved with an EHR implementation knows that almost one year is needed from implementation to full productivity. 3. Proprietary Software- " Any hospital can interoperate with Epic's Care Everywhere- just so long as they are an Epic institution." 4. As more and more new physicians and providers are trained in Epic, they will push for the same EHR in their new institution due to familiarity.

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CMS’s 2025 #Medicare proposal is a game-changer for virtual care, expanding coverage for #telehealth and #digitalhealth tools. This proposal empowers providers to meet patients where they are, making healthcare more accessible and efficient. It's a bold move that signals the future of #caremanagement is not just in the office but in the digital space! #providers #Payers

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Many thoughts as Medicare Advantage continues to come under scrutiny. - MA has features of a value-based program, but most of the current "value" is being delivered through diagnosis capture and complexity payments. Ironically, much like FFS, it pays more to keep people sick (or make them look sick). Don't think that's anyone's definition of value. - To be fair, most doctors (especially specialists) don't do a great job of capturing diagnosis and patient complexity beyond their immediate area of expertise. (We're especially bad at this in MSK). We should have accurate representation of a patient's health in the medical record. Complexity and co-morbidities affect treatments and outcomes. We don't yet have a good way to account for this complexity -- and it's becoming clear the MA system isn't it. - EMRs make all of this worse. It's both too easy and too hard to record, change, or resolve diagnoses. EMRs should facilitate accurate complexity capture and treatment personalization. The goal shouldn't be to increase billing, it should be to increase sophistication and precision. - As MA scrutiny grows, the business model of many alternative care models (especially in primary care) will be challenged (potentially dealing another blow to retail healthcare). - CVS' purchase of Signify health is put into full context by this article. - It boggles the mind that CMS can develop and administer a program that nets billions for inscos (at the expense of taxpayers) while reducing physician reimbursement yearly and rolling out ineffective VBC programs for providers. CMMI should have an open-door policy for anyone delivering care and working on true value-based models. Ears, eyes, and minds should be wide open. h/t Mahek Shah MD, MBA Moby Parsons, MD #medicine #healthcare #vbc #valuebasedcare #health

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Prior authorization Post—Part II Cohere completes the case report with some impressive statistics on provider and patient satisfaction, better quality and reduced cost, none of which I can verify. But new technology does seem promising—why cannot an artificial intelligence-based program interrogate the medical record, apply best practice and suggest an optimal approach to care, in an instant or two, that could ground the discussion between insurer and patient/doctor. Some regulation is moving in this direction. Joseph Kannarkat, Wendy Warring and I recently reviewed CMS regulatory efforts to push insurers toward automation. Proposed federal legislation also has the same impulse, such as the Improving Seniors’ Timely Access to Care Act. Insurers seem to be getting the message that moving away from gatekeeping and toward collaboration will be necessary. Yet the question remains, can prior authorization survive the ever-building animosity of providers and patient, which brings one back to the terrible story of John Cupp, related by ProPublica, who died of a heart attack as his doctors fought with Evicore about doing a cardiac catheterization. It is nothing other than a tragedy, but the ProPublica story leaves a number of questions unanswered. Most importantly, existing cardiology care guidelines would have suggested a cardiac CT scan with functional flow reserve analysis (a great example of the use of artificial intelligence in medicine today) rather than the nuclear stress test that was recommended and completed for Mr. Cupp. CT with FFR is a test insurers pay for, as it provides the necessary information for medical management and avoids expensive catheterizations. Tragedy may have been averted, and the health care would have been high quality and efficient, if the PA process had pointed to this solution. It is not too far-fetched to imagine that an AI program could have analyzed the medical record and suggested CT scanning analytics for the physicians and insurers, especially if the program was based on analysis of the standard of care and scrubbed of bias around expense. In the pre-election political environment, it was difficult to see how insurer-based prior authorization could be saved, even if it should be saved. Perhaps the new Administration will change all of that, rolling back ACA-based protections, and concerns about prior authorization will fade. That seems doubtful, but possible. In any case, though, use of better technology to assure care that is high quality and value-based will become ever more important as health care costs continue to rise.

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New Medpac report raises questions about prior auth But… “In 2021, MA plans made about 37.5 million prior authorization determinations, or about 1.5 determinations per enrollee. Overall, we found that 95 percent of prior authorization requests had fully favorable decisions.” “Providers or beneficiaries requested that MA plans redetermine 11 percent of negative prior authorization decisions in 2021. Eighty percent of those requests had fully favorable decisions. For those requests that had an unfavorable decision, an independent review entity upheld the MA plan’s decision most of the time” BUT..the report doubles down to say: “Office of Inspector General audits suggest that many denied requests should have been approved.” “We selected a stratified random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest MAOs during June 1-7, 2019.” Hmm off the cuff it seems like of the almost 1.9 M that’s not statistically significant. What the data show: The providers seem to be reluctant to appeal many of the denials as only a little more than 1 in 10 of the denials are appealed. And 1.6M are not approved or appealed. Besides the underpowered OIG report, the report quotes the burden on the doctors and is fairly consistent with a consensus-based Commission with 4 hospital Commissioners. As always I want to know more for instance Part B drugs are the largest segment - what part b drugs had prior auths and why. (See in comments for the answer.) #MA #Oncology #priorauth

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"ACD": The Unlinked Chart Reviews for #OIG Audits! This can be from a Home Risk Assessment (HRA) by the health plan but the provider has no insight to the conditions found. Here’s what happens: → The beneficiary has the condition as captured by the plan. → The provider’s system lacks any record of the condition. → The health plan has the condition and sends it to CMS. → CMS pays based on the plan’s submission. Why is this an issue? Providers are unaware of the condition. Beneficiaries may not receive proper services. Health plans face #OIG audit risks for unlinked chart reviews. What’s the cost? Reports on "untreated services" during audits. Missed care opportunities for beneficiaries. How to address it: ☑ Improve provider-plan communication on home risk assessments. ☑ Reconcile diagnoses across systems before submitting to CMS. ☑ Train health plans to align data and services. Accurate alignment ensures services match diagnoses, reducing risks and improving care. ♻️ Repost to help others navigate this challenge. 👤 Follow for more insights on Risk Adjustment.

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