Kate Goodrich

New #ManattOnHealth Insight by Julian Polaris and Katie (Rubinger) Platz: A new GAO report investigates #PriorAuthorization practices for children enrolled in #Medicaid #ManagedCare organizations (MCOs). #CMS agrees that some clarification is needed and may consider additional rulemaking or guidance to address these issues. For more, read Manatt’s latest newsletter. 

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A brief thread on how MLR is often a stat that is juked (h/t to The Wire) in the “value-based” care world. The medical loss ratio (MLR) is a financial metric used in health insurance and managed health care to measure how much of a premium dollar an insurer uses to pay medical claims and quality improvement activities. The MLR is also known as the medical care ratio, medical cost ratio, or medical benefit ratio (cite: Healthcare.Gov). Many so-called value-based care models cite their impact in the form of medical loss ratio improvement. Most innocently assume that such improvement is generated by better medical management (I did when I first started working in the field). While this may be the case in some models—it is importantly to note that another way to improve a medical loss ratio is be increasing revenue capture in the form of coding. Said another way, to improve MLR, one can reduce the numerator or increase the denominator. Therefore, when someone cites a major medical loss ratio improvement—the key question to ask is: did the MLR improve because of true medical utilization reduction or because of better revenue capture? Most will glibly (and sometimes dishonestly) say “both.” At which point it’s important to ask, what fraction of Medical Loss Ratio improvement arose from better medical management and what fraction from better revenue capture. Usually, what we will find is that most dramatic improvements in MLR are a function of improvements in revenue capture—and only marginal improvements in medical cost-management. In that way, the so-called “value” produced by many value-based care models isn’t true value. It’s better revenue capture. And many “value-based” care models have been granted undue recognition for medical cost management—citing filthy MLR improvements—that are associated with minimal true improvement in medical expense. This kind of short-cut taking sets back the whole value-based care movement which (while appropriate revenue capture is necessary) should be about overall better cost management and reducing total cost of care—not better revenue capture alone.

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New CMS guidance clarifies Medicaid and CHIP payment policies for pediatric #palliativecare, aiming to improve access and reduce disparities for seriously ill children by expanding early screening, care coordination, and workforce support. https://bit.ly/3Ya3rHu

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Most viewed in the last 7 days from JAMA Health Forum: This JAMA Forum discusses the responsibilities of public health agencies that overlap with those of the CDC and argues that the role of the CDC could be redirected to better meet the needs of its core mission. https://ja.ma/40jMUU6

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Introduction of Medicaid APM options for federally qualified health center (FQHCs) was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. https://ja.ma/4daDw8H

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How are stakeholders integrating the patient perspective into health technology assessments? What are the implications for evidence strategy, health equity, caregiver involvement, and care delivery? A recent panel of #AvalereExperts and external colleagues answers these questions and more: https://lnkd.in/eRmFB-vP Featuring Laura T. Housman, MPH, MBA, DrPH(c), Mina Alsaraf Allo, Shelby Harrington, Nikki Martin, Claire Saxton, and Joey Mattingly #HealthTechnologyAssessment #HTAs #healthequity #patientperspective #patients

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In 27 states and Washington, D.C., NPs have Full Practice Authority, giving patients direct access to primary care providers. States with FPA consistently rank higher in health outcomes—because when NPs can practice fully, everyone benefits! #NPWeek2024 #FullPracticeAuthority

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Partners in health information: Mutual subscribers of EBSCO Discovery Service (EDS) and Elsevier’s ClinicalKey can now discover and access journal articles and book chapters indexed in ClinicalKey products via EDS. Learn more: https://m.ebsco.is/uhid0 #LibraryDiscovery #ClinicalResearch #EvidenceBasedMedicine

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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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New #LitReview 📚 With funding from the AIR Equity Initiative, AIR experts developed a literature review series that offers insights into how #Medicaid can advance maternal health #equity. We focused on three coverage policies: #postpartum home visits, freestanding birth centers, and long-acting reversible contraception.

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Another section of the #FinalRule has been released by #CMS aimed at enhancing #access to and #transparency of #Medicaid services, including #HCBS. This rule pairs with two other final rules published in April 2024 that focus on improving Medicaid #eligibility and access to Medicaid services. This rule is focused on an #FFS system, but the impact could involve changes to underlying FFS rates in base #data for #ratesetting and program #oversight in #MLTSS. Dianne Heffron and Meredith Mayer of Mercer US Government have conducted a review of the proposed and finalized rules. https://bit.ly/3QuGRXe

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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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In this article, the authors discuss apply the PRISM framework w/ an equity lens to assess implementation & context, emphasizing the importance of representation, unintended consequences, capacity building, and sustained assessment of equity. 📎 https://lnkd.in/g26pvE_n

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New #ManattOnHealth Insight by Julian Polaris, Anne Karl, Patricia Boozang, Tracy Johnson, Ph.D. and Melinda Dutton: Exciting News – #CMS has finalized significant new rules for #Medicaid and #CHIP, impacting over 85 million beneficiaries nationwide. With some notable exceptions, CMS finalized the 2023 proposed rule with only modest changes. #Healthcare #PatientAccess #HealthEquity #HealthPolicy 

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Will a new wave of physician unionization counteract the consequences of #hospitalconsolidation? Can #unions help satisfy physicians’ interest in governance and restore some professional autonomy? The latest paper by BAHM President Kevin Schulman, Stanford CERC, and Barak Richman, Duke University School of Law: https://lnkd.in/gfxniKPV Or see the PDF: https://lnkd.in/gDFCx5b6 #healthcaremanagement

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Partners in health information: Mutual subscribers of EBSCO Discovery Service (EDS) and Elsevier’s ClinicalKey can now discover and access journal articles and book chapters indexed in ClinicalKey products via EDS. Learn more: https://m.ebsco.is/ug9LJ #LibraryDiscovery #ClinicalResearch #EvidenceBasedMedicine

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WCM-Q webinar series sees experts discuss contemporary population health issues https://lnkd.in/drsqH_4A

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