Kevin Thilborger

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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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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The latest VMG Health report indicates a shift in hospital financials, with the median operating margin increasing from -0.9% in 2022 to 2% in 2023. Leaders from major health systems report a more stable labor market and consistent operational improvements, reflecting a cautiously optimistic outlook for 2024. #CFOs #OperatingMargins #FinancialPerformance https://lnkd.in/efkSZYvV

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CMS recently issued its Medicare Hospital Inpatient Prospective Payment System (IPPS) final rule for FY 2025. In addition to Medicare fee-for-service payment rate changes, the rule establishes a number of other updates, including changes to required quality data reporting. Key highlights related to reporting changes within the IQR program: • Two new healthcare-associated infection measures applying standards used in other areas of care to oncology locations, beginning calendar year 2026. • Two new electronic clinical quality measures (eCQMs) options relating to falls and postoperative respiratory failure patient-safety practices, beginning calendar year 2026. • Renewed requirements for sustained data collection and reporting of respiratory illnesses—COVID-19, influenza, and RSV—with the requirement that this information be reported electronically by Nov. 1, 2024. See the CMS IPPS fact sheet for a full summary of the final rule: https://bit.ly/3WzrD5f At Q-Centrix, we work with hospitals and health systems to prepare for changes stemming from the final rule updates each year while improving their public quality measures reporting efforts with respect to core measures, eCQMs, Infection Prevention, and other types of required reporting. It's my passion to see hospitals improving patient care by utilizing the high-value data being collected as part of these programs. Comment or message me if you think we can help you with better leveraging your data!

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Register to close care gaps using CDI: https://lnkd.in/gXRqb3Be Healthcare disparities plague the industry, leading to worse health outcomes for specific member groups. Traditional administrative claims data often lacks the clinical granularity needed to expose the full picture. This webinar tackles the power of Clinical Data Integration (CDI) in identifying these hidden disparities. Leverage the expertise of Health Chain as we delve into how CDI programs can analyze clinical data to reveal: 🎯 Disparities in Dx/Px Rates: Unearth discrepancies in diagnosis (Dx) and procedure (Px) rates across different member segments. This unveils potential under-treatment or missed opportunities for early intervention in high-risk populations. 🎯 Preventive Care Gaps: Uncover potential differences in preventive care utilization across different member segments. Racial and ethnic minorities often experience lower rates of preventive screenings compared to white populations. 🎯 Leverage CDI to identify these disparities and develop strategies to close the gap and improve overall population health. 🎯 Social Determinants of Health (SDOH) Impact: Social factors like income, education, and access to healthy food significantly influence health outcomes. 🎯 Leverage CDI to identify SDOH impacting specific communities within your member base. Here from Nikita Ravindran and Vinay S. how Health Chain’s robust CDI solutions can be used to identify these disparities within your member population. Tune in at 1pm CST | 11am PST on 27th September 2024 to learn practical strategies to leverage rich clinical data captured through CDI for developing targeted interventions and improving health equity for all members. Bonus for attendees 📣 Get a free copy of Gartner’s report on “How Clinical Data Integration Improves U.S. Healthcare Payer Interoperability” #CDI #Caregaps #populationanalytics #healthcaredata #FHIR #payers #HCwebinars #Gartner Sudheen (Sudheendra) Kumar Mason Burr

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Medicaid Strategies for Long-Term Coverage Improvement In preparation for Medicaid’s 60th anniversary, a new ACAP report discusses strategies for enhancing Medicaid coverage and addressing equity gaps. Key areas include expanding access and adapting to the changing healthcare landscape. https://hubs.la/Q02Xyv4x0

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Excellent article by Nona Tepper at Modern Healthcare explaining how Medicare Advantage #starratings are calculated and how they impact member recruitment. While they're not perfect, Stars ratings provide a good quality indicator for those choosing a plan. Check out the article here. Nona Tepper Modern Healthcare

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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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There’s renewed optimism for the passage of the Improving Seniors’ Timely Access to Care Act, a bill aimed at simplifying how payers process healthcare utilization requests in Medicare Advantage plans. Recent updates have brought the bill closer to budget neutrality and would require Medicare Advantage plans to report their approval and denial rates, develop electronic prior authorization to streamline approvals and encourage adherence to evidence-based guidelines. Supported by hundreds of organizations, this bipartisan effort could significantly reduce delays in access to necessary healthcare services. Continue reading at https://loom.ly/UkTTZP8

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https://lnkd.in/gMUpgFgC Check out Beterra's latest blog, and check back for more Beterra thoughts on the CMS Proposed Patient Safety Structural Measure (PSSM). #healthcare, #safety, #cms, #pssm

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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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With 41 states, including DC, adopting Medicaid expansion, Utah’s #Medicaid overhaul is a standout example of how advanced procurement and implementation strategies can enhance healthcare access and quality.   Medicaid system overhauls are crucial as they directly impact millions of individuals, ensuring they receive the necessary healthcare services. Effective modernization efforts can lead to improved health outcomes, reduced #HealthDisparities, and better resource allocation. Utah Department of Health and Human Services, along with Acentra Health, successfully implemented advanced strategies such as early engagement, precise criteria setting, and rigorous quality assurance testing. These efforts reflect broader trends across the country, where states are working to enhance their Medicaid programs to better serve their populations.   If you're attending #MESC2024, don't miss this opportunity to gain actionable insights and apply best practices to your state’s #Medicaid #modernization efforts. To learn more: 📅 Attend our upcoming session at #MESC2024 – add the session to your calendar here: https://hubs.li/Q02J0mhq0 📊 Sign up for the latest Acentra Health Impact Report for the full Utah Medicaid overhaul success story: https://hubs.li/Q02J0t0F0

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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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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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The time is now: Why addressing your revenue cycle challenges is critical in 2025 for healthcare leaders. Take a look at our eguide in the link below.

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