Kimberly S. (Kim) Foltz

As the 2025 Medicare Advantage (MA) enrollment season approaches, experts note significant challenges and changes in the landscape. The CMS has adjusted its payment models, impacting how health plans are reimbursed based on patient health conditions. This has led to a noticeable decline in the number of available plans, with major insurers like CVS and Centene cutting over 60 plans each, resulting in fewer carriers and increased plan terminations. Despite these challenges, enrollment in Special Needs Plans (SNPs) has surged, more than doubling since 2019, driven by the growing demand for tailored care for vulnerable populations. SNPs now account for 20% of overall MA enrollment, highlighting a significant shift towards specialized care amid broader market fluctuations.

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Between 2016-2018, the average cost for an inpatient visit related to a fall was estimated to be more than $18,000. That is a staggering number when you align it with the fact that falls are the leading cause death and injury among seniors age 65 and older! Let's bend the curve on expenditures related to falls and be proactive with our members! #Medicare #SSBCI #MedicareAdvantage #Medicaid #CMS #DHS Sources: https://lnkd.in/g9AArGGS. https://lnkd.in/gt2g2EdZ

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Keep our rurals open but if you really want to help get the foreign equity owned GPO that sets the pricing for our hospitals BANNED from our state. Economies of scale are used by Vizient against Oklahoma rural hospitals. If you have 13 tiers, hidden tiers, and tier maxes…that’s not a contract, that a free for all nightmare of a scam we all fell for. Their awful written tiered agreements force our rurals to pay more for the exact same items that our large hospitals pay less for. Example box of gloves a large hospital system in the state will pay 6-8 bucks for a box of 250 exam gloves. That same box for a rural EMT? 24 bucks. There is no price transparency and you are forcing patients who live in rural areas to pay more because of the lack of infrastructure by the corporations serving them to effectively and economically get goods and services to these hospitals. And distributors who whine about the cost of delivering to rural hospitals all while posting BILLIONS in profit every quarter are the first on my 💩 list. Let’s keep our rurals open but let’s make them more profitable so that they can continue to add much needed services and gainfully employ more community members.

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Want some free consulting on a blazing hot topic in our industry (not called AI)? Read on and please reach out if you want to discuss more!

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The highest increase since 2012 highlights the pressing need for further action to curb increases in medical cost trend. Insurers should prepare for tougher contract negotiations as providers strive to enhance their financial standing and offset stagnant Medicare and Medicaid reimbursement rates.

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There is no doubt that we are in the throes of a mental health crisis in this country. Reaching people where they are, when they need it the most is a huge challenge. Digital tools can begin to address this by providing necessary support in an accessible way. #elevancehealth #carelon #behavioralhealth #digital

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This commentary from Sachin H. Jain, MD, MBA is extremely timely and aptly captures the shifting landscape within #MedicareAdvantage. It underscores that providers who can establish meaningful, real-world partnerships with at-risk #primarycare practices—especially those targeting high-cost areas like #emergencyroom and hospital utilization—will be crucial in driving down both costs and unnecessary utilization. GuideWell Emergency Doctors is a prime example of how such partnerships can maintain high-quality patient care even as the focus shifts from revenue maximization to #valuebasedcare. In this environment, efficiency and effectiveness are no longer optional; they’re essential to staying competitive amidst these widespread industry changes. ▶️READ NOW: https://lnkd.in/ehMsYejG

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What is particularly interesting about this CMS report is the emphasis on data - access, utilization and reporting. Particularly as we focus on alternate models of delivery and funding in the rural and community setting. Having spent a lot of time with these hospitals, I know first hand how resource constricted may of them are (financial, technological, human and skills). As a Health Data Management company, Orion Health are poised to support this segment in need and welcome any questions on how we can. #ruralhealth #healthdata #cms

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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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This recent ruling by the appeals court to eliminate #Medicare supplemental payments for low-wage hospitals highlights the challenges faced by healthcare facilities serving vulnerable populations. These hospitals, already operating on razor-thin margins, will now have to find ways to compensate for the loss of millions of dollars in annual payments. This decision raises important questions about the equity and fairness of the current healthcare reimbursement system. Should hospitals that serve low-income communities be penalized for their geographic location and workforce demographics? How can we ensure that all patients have access to high-quality care, regardless of where they live or their economic status? We need to advocate for policies that promote equity and support the viability of hospitals serving underserved populations. It's time to rethink our approach to healthcare reimbursement to ensure that all patients have access to the care they need. #healthcareequity #patientsfirst

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As we move forward with our business model, this Health Affairs article resonates -

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How can we teach children about what it means to be healthy and to thrive? Children who are healthy in mind, body, and heart can thrive in every way. Mental health IS health! Check out the link in this blog to the great mental health resource videos produced by Sesame Workshop. Timeless wisdom for all ages! #childrensmentalhealth #sesameworkshop #unitedhealthcare

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Thank you, BHBusiness for shining a light on an important topic. As the article suggests, hospitals are not reimbursed nearly enough for their out of pocket costs to deliver behavioral health services, but as the article also wisely notes, outpatient behavioral health services actually fair even worse in terms of reimbursement. Providers being reimbursed $0.32 cents on every dollar it costs to deliver care is unsustainable. For outpatient providers, the federal Certified Community Behavioral Health Clinic (CCBHC) designation offers hope and is a step in the right direction. Although the reporting requirements are significant, the care model is more holistic and the approach to reimbursement incentivizes quality and visit efficiency while determining payment rates using actual costs. We have a long road ahead of us, but at least the federal government recognizes this inequity. Some states (New York, to name one) are also taking matters into their own hands, and are working on improving payor reimbursement for safety-net providers.

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Discover how Making Care Primary (MCP) is transforming community-based healthcare with a focus on integrated care and #behavioralhealth. This innovative initiative launched across eight U.S. states and 772 practices aims to empower primary care practices to deliver comprehensive, patient-centered care. Read the blog from Ian Laster to learn more: https://okt.to/HC5cNI

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A people-first mindset is crucial as digital technologies and AI become bigger influences in healthcare. In fact, Gail Boudreaux, president and CEO of Elevance Health, discussed at CES 2024 how tech and data-driven insights can promote more proactive and personalized care. Here are some key points she made during her keynote address. https://ow.ly/6SCY30sEjzo

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Proud to Share Another Strong Quarter for Sienna Senior Living! Our third quarter marked another period of progress and success as we continue to grow and strengthen our impact on senior living: 🔹 Operating results improved for the seventh consecutive quarter 🔹 Recent capital-raising initiatives were met with overwhelming demand from investors 🔹 Our recent $182 million acquisition in Alberta marks a successful step in our expansion, enabling us to serve even more seniors across Canada These accomplishments did not happen by chance. They are the result of a continued commitment to improving our operating platforms, strengthening team member engagement, and driving forward our growth strategies. As we expand the number of seniors we serve, we are more committed than ever to prioritizing team member engagement and retention as a cornerstone of our success. Our 12,500 team members are the reason why we can care for nearly 12,000 seniors, and as owners of the company, they are deeply aligned with Sienna's success. David H., Jennifer Anderson, Geoff McIlmoyle, CFA, CPA, CA, Teresa Fritsch, MBA, MA, ICD.D, Olga Giovanniello M.Ed, C.Dir., Adam Walsh, Nancy A. Webb and I look forward to continuing our growth trajectory with them.

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The new federal Medicaid managed care rules include a focus on access to care. Rules will be implemented over time and may have significant implications for states, plans, and enrollees. Here are 10 things to know about managed care:

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