Kristen Woods

Shifting the financial model alone is not sufficient for the transition - the care delivery, workforce, and many other pieces of the ecosystem with which PCPs interact also need to adjust accordingly. Funding to allow for the startup costs of transformation must be made available. A comprehensive analysis from The Commonwealth Fund: To encourage participation, practitioners say upfront payments, investment in the primary care workforce, and less emphasis on simplistic quality measures are needed, as well as more support for practices to provide accessible, comprehensive care. #primarycare #integratedcare #teambasedcare #healthcare #healthcareonlinkedin

120

11 Comments

🔩 Q: What is a Bolt on healthcare benefit? ✅ A: Great question! Self-funded ERISA-governed plans may add on OPTIONAL services to provide more options for members and potentially save more time and money for both plans and members. We call these "bolt-on benefits" in the industry. Here are some examples, and even focused examples on #prescriptiondrugs and #pharmacy: 💊 -On site or near site clinics - that can provide quick appointments for members to get in to the doc or provider when their primary care providers are not available. At these clinics, members can obtain many drugs at these on site or near site clinics at a discount or even free to get them started and up to 100% of the drugs could be charged back to the plan. 💊 -Canadian drug importation programs - patients are allowed legally to personally import drugs with several stipulations (not biologicals, not controlled substances). I will reserve my personal opinions on these Canadian programs for now, but just know that they can be another option for members. 💊 -Cash pay on prescriptions and applying the cost to deductibles and OOPs - especially for the 1/3 of plans that are High Deductible Health Plans (HDHPs) - your plan, if you have a savvy consultant or broker, can set up a program to allow those with HDHPs to apply their receipts to their deductibles and out of pocket accumulators at the beginning of the plan year when patients have to pay out of pocket. You MUST ask your broker, however, if they can set up this option for your plan with the medical carrier, and show a clear pathway at open enrollment for members on where they may turn in their receipts to apply to their deductibles. 💉 Example: 1/1/25 is right around the corner and 70% of plans' accumulators will reset. With the Team Cuban Card, for example, people may pay cash of $748+ cash price with Yusimry, an adalimumab biosimilar, (https://lnkd.in/g5gJz_Mf) or they can purchase a more expensive option on their drug formulary. Why not take advantage of better cash pricing and rewarding the member for finding it and applying it to the deductible? 🛑 Now that the breach of fiduciary lawsuits have arrived, considering bolt on benefits is/are another critical component for plans to explore. If you offer your members options, you're demonstrating that one way your plan is meeting their fiduciary obligations. Maybe all these won't work for your plan.....but you miss 100% of the shots you never take. #pharmacybenefits #pharmacy

3

1 Comment

'PRIVATE INSURERS involved IN the government’s MEDICARE ADVANTAGE program MADE HUNDREDS OF THOUSANDS OF QUESTIONABLE DIAGNOSES THAT TRIGGERED EXTRA taxpayer-funded PAYMENTS from 2018 to 2021, including outright wrong ones, a Wall Street Journal analysis of billions of Medicare records found, RESULTING IN TENS OF BILLIONS OF DOLLARS IN EXTRA COST. The questionable diagnoses included some for potentially deadly illnesses (such as AIDS), for which patients received no subsequent care, and for conditions people couldn’t possibly have, the analysis showed. Often, neither the patients nor their doctors had any idea. Medicare Advantage, the $450-billion-a-year system in which private insurers oversee Medicare benefits, grew out of the idea that the private sector could provide healthcare more economically. It has swelled over the last two decades to cover more than half of the 67 million seniors and disabled people on Medicare. HOWEVER, instead of saving taxpayers' money, Medicare Advantage HAS ADDED TENS of BILLIONS of DOLLARS IN COST, researchers and some government officials have said. ONE REASON IS THAT THE HEALTH INSURER CAN ADD DIAGNOSES to ones that the patients’ own doctors submit. Medicare gave insurers that option so they could catch conditions that doctors neglected to record. The Journal’s analysis, however, found MANY DIAGNOSES WERE ADDED FOR WHICH PATIENTS RECEIVED NO TREATMENT, OR THAT CONTRADICTED THEIR OWN DOCTORS' ASSESSMENT.' For example, UnitedHealth members were about 15 times as likely to have that diagnosis of diabetic cataracts as the average patient in traditional Medicare, the Journal analysis found. Eye doctors interviewed by the Journal said it was implausible that such a large share of UnitedHealth’s patients could have the relatively rare disease. The government paid all Medicare Advantage insurers more than $700 million from 2019 to 2021 for diabetic cataracts. Most of the diagnoses were added by insurers. SOME DIAGNOSES claimed by insurers WERE demonstrably FALSE, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery, which replaces the damaged lens of an eye with a plastic insert. “It’s anatomically impossible,” said Dr. Hogan Knox, an eye specialist at University of Alabama at Birmingham. “Once a lens is removed, the cataract never comes back.” And insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated generated $8.7 billion in 2021 payments to the company, the Journal’s analysis showed. UnitedHealth’s net income that year was about $17 billion. The Wall Street Journal consulted more than a dozen experts, including academics, actuaries and policy analysts, about its analysis of the Medicare data, who said the methodology was sound.

3

What does health insurance do? The conversation in the attached screenshot sums it up. We have a distorted market in healthcare. For drugs, there is a middleman called PBM between the insurance and the drug companies. The PBM negotiates a higher rate than the cash price - usually 2x or 3x and then receives an under the table rebate from the drug company. It passes of portion of this rebate to the insurer. The end effect is that the bottom price for the consumer is increased. The consumer believes that their insurance saved them a lot of money. #healthcare

2

ASCs Advocacy Efforts 🤝✍️ There are a few challenges ASCs face due to Medicare policies, but there are also efforts underway to address them: *Reimbursement disparity: ASCs receive lower payment rates for procedures compared to hospitals, disincentivizing some procedures in ASC settings. *Patient cost-sharing: For some procedures, the lack of a copay cap in ASCs can lead to higher patient out-of-pocket costs compared to hospitals with a capped copay. *Procedure code restrictions: Some complex procedures are coded as "inpatient only" limiting ASC options. Here's what ASCs can consider: *Advocacy: Ambulatory Surgery Center Association (ASCA) is lobbying for policy changes. ASCs can join ASCA and support their efforts for fairer reimbursement. *Focus on cost-efficiency: ASCs can leverage their lower overhead costs to provide competitive pricing for certain procedures, making them an attractive option for patients and insurers. *Patient education: ASCs can educate patients about the benefits of ASC care, including potentially lower costs and faster recovery times, to help them understand the potential cost advantages despite the lack of a copay cap. *Collaboration with policymakers: ASCs can work with legislators and regulatory bodies to advocate for policies that promote fair competition and patient choice based on the most appropriate setting for care. Legislative efforts are also underway. The "Outpatient Surgery Quality and Access Act of 2023" aims to remove disincentives for ASC growth by creating a budget-neutral system. Stay informed about these developments and get involved in advocacy efforts to help ensure a fair and competitive environment for ASCs. credits to Patsy Newitt

2

📣 Wake-Up Call for Physicians! 📣 While we were immersed in our daily routines, a significant shift occurred in the healthcare landscape. Here’s a snapshot of the Producer Price Index (PPI) for hospitals and physicians from 2007 to 2024. 📊 The graph paints a clear picture: the lion’s share of the excessive healthcare expenditure 💰 was claimed by hospitals, not physicians. But that’s not the whole story. Dig a little deeper and you’ll find that a substantial portion of the hospital funds (not shown in this graph) were channeled into administrative bureaucracy. 🏥📑 We’re at a pivotal moment in healthcare. It’s time for us to take note, engage in meaningful discussions, and drive change. I’d love to hear your thoughts on this. Let’s start a conversation! 💬 Graph created from Producer Price Index (PPI) data published by US Dept of Labor #Healthcare #Physicians #Hospitals #HealthcareExpenditure #PPI

2

I looked again at the at the Association of Healthcare Value Analysis Professionals (AHVAP) website. Not to my surprise, the Board membership remains unchanged. Nine Board members, and one "Ex-Officio Board Member. Of the nine Board Members, seven remain organizationally attached to one GPO. In my opinion, this remains a serious conflict of interest, and feels like an ethical concern. Those who care about conflicts of interest and unethical practices know what they look like. That this Association is unconcerned about their lack of independence should be a concern not only for the membership of this organization, but for any prospective members and for all health systems who have employees looking to this Association for value analysis leadership. Value Analysis is broken. It's not working. The evidence is available in the many metrics easily attainable that relate to continually rising supply costs, and quality of care reductions. "Proposed savings" are not "Realized savings". What I see from the AHVAP are illustrations of "proposed savings" to indicate their success. Open the books and show it's realized savings! It's appropriate that the AHVAP would be tied to a GPO in that they both are responsible for taking health systems money to provide a service that is failing our healthcare cost and quality structure. On a funny note, look at the AHVAP website. The Ex-Officio Board Member is listed as: Executive Director & Executive Vice President  AHVAP Dr. J. Hudson Garrett Jr., Ph.D., MSN, MPH, MBA, FNP-BC, IP-BC, PLNC, VA-BC, BC-MSLcert™, MSL-BC, CPPS, CPHQ, LTC-CIP, CIC, CPHRM, ICE-CCP, CVAHPTM, CPXP, CDIPC, FACDONA, FAAPM, FNAP, FACHE, FAOM, FSHEA, FIDSA, FAHVAP Twenty-seven certifications, education initials, qualifications. Dr J Hudson Garret Jr wins the award for the most time spent with his nose in a book, and the least time spent owning a profit-loss statement. These are the academics we're allowing our health systems and employees to take direction from. When I was in the military, we called what Hudson Garrett illustrates on the AHVAP website an "I Love Me" wall. Sorry Hudson, just recognizing what you put out there for me to see.

3

4 Comments

Humanizing healthcare through collaboration. In my approach, I'm deeply committed to igniting change at its core. Challenging the status quo isn't easy, but as a bold leader, I'm always eager to embrace the challenge. My aim is to collaborate with the right great minds in the industry , like Alvin Gore, MD leading the charge at UM and collaboration in care through coding CDI and providers. In addition to Cesar M. Limjoco, M.D. , to revolutionize patient care through innovative practices and insights for Sepsis and quantitative fallacies in diagnosing. I am inspired by Zeev Neuwirth, MD "Reframing Healthcare," I'm driven to unravel the legacy framework that hinders efficiency and quality, aiming to reshape healthcare for the better. Dr. #Zeev puts it so well, “our brains are wired in a legacy framework that is engrained in higher cost, lack of efficiency and quality of care for our patients”. Together, let's embark on this transformative journey, rallying all clinicians, & all healthcare leaders, to join the movement towards a more compassionate and effective healthcare system. Vasanth Kainkaryam, MD, MSHI, CPE, ADS, FAAP, FACP, DABOM thank you for your dedication, passion,and contribution to this noble cause. Together, we can truly make a difference through education and thought driven solutions.

10

6 Comments

Some keen findings from this well researched Health Affairs: 1) "... the types of payment models and types of employing organizations are determining factors in VBC participation. The factors influencing the intensity of participation align with those affecting the extent of participation: those most likely to participate tend to do so across multiple models." --> If you're looking to grow your value-based network, best to look for current value-based providers and look to add them to a new model. 2) Specialists are no where meaningfully engaged in value-based care, "Policymakers have numerous opportunities to better engage specialists in a true team-based care approach". --> This concurs with where venture capital has been looking to place investment, the opportunity and need to grow specialist enablement. 3) OB/Gyn are the specialists most associated with capitated payments, "Obstetricians/gynecologists showed a higher likelihood of participating in capitation, which promotes coordinated care. This is consistent with payment schemes for obstetricians/gynecologists" --> Pregnancy as an episode, is likely still the easiest bundle for payers and provider to contract.

14

#Nurses and #doctors are noticing firsthand that anemia is growing faster globally than we ever thought. They truly represent a new culture of first responders in this critical area of healthcare. We hope that medical colleges, #hospitals, and nursing associations will support awareness of the vital roles these healthcare professionals play in serving the public's needs. These healthcare providers, along with many companies, also represent the foundation of potential cures for anemia worldwide. Consider this: The smallest amount of air blown into a balloon will automatically increase its size and visibility. The relationship between healthcare providers and anemia needs to be seen on a much larger, broader scale—just like that balloon. This also enhances the dignity and respect they’ve always deserved. We can't afford to let this balloon deflate, as doing so would set us back significantly. Our work focuses on building bridges that bring healthcare providers closer to understanding the patient. We’ve created a meaningful insignia for doctors and nurses that fosters trust and understanding from the very first examination. This is a new concept for #anemia, and we anticipate new partnerships and ideas that will expedite awareness even further. Until then, we deeply appreciate all collective efforts—together, we will defeat public enemy number one: Anemia. UChicago Medicine Englewood Hospital Cleveland Clinic Mayo Clinic Geisinger Johns Hopkins Medicine Loma Linda University Health Hackensack Meridian Health Penn Medicine, University of Pennsylvania Health System Mount Sinai Health System NewYork-Presbyterian Hospital MedStar Washington Hospital Center American Society of Hematology American Nurses Association American Academy of Anesthesiologist Assistants UCLA Health Yale New Haven Health Jefferson Health NYC Health + Hospitals

13

Activation and engagement are critical pieces to a #primarycare model that seeks to manage a population proactively.

40

Consider the role of complexity not from the top down or the designer perspective, but from the bottom up - the patient and delivery team member perspective. You might see the increasing challenges of More to do (micromanagement, digitalization, regulation, certification) fewer team members (lower ratios) and lesser delivery team members (replacements of experienced team members by less experienced, made much worse by massive expansions of annual graduates as in NP PA and DO) ... to share the increasing complexity in many dimensions (patient, practice, community, relationships, environments, insurance quality poor made worse) ... and despite less time ... and despite disruptions of personal and professional lives ... that prevent best on on one innovation with each patient ... thus shaping moral injury, burnout, turnover, higher turnover costs, and even worse finances in practices and hospitals

5

2 Comments

✍️ A new essay: "For an Unremarkable Health System" 🏃🏼 We often celebrate remarkable achievements in healthcare — hospitals excelling on certain metrics or clinicians winning prestigious awards. But what if we shifted our focus to pursuing an “unremarkable” healthcare system instead? I examine this thesis in a new essay for Healthcare Quarterly. 🚶🏼 An unremarkable system performs consistently well across all indicators that matter to patients, without major deviations. It delivers “decent enough” results deserving of careful monitoring, but nothing remarkable that raises concerns. Rather than chasing a few standout metrics, an unremarkable system provides a balanced, holistic experience for patients across the care continuum. It seeks to maximize health and welfare for everyone by lifting all boats through quality improvement. Unremarkability requires a culture change from our tendency to seek to outclass peers. Doing “okay enough” all the time may be better than excelling in some areas while failing in others that impact patient care. 🙏🏻 Thank you to my editors at Longwoods Publishing… and to Zain Mujtaba, a spark of inspiration to me on this topic, and so many more! Neil Stuart Anne Wojtak Susmita Dey Dalla Lana School of Public Health, University of Toronto

4

1 Comment

Have you established a governance structure for adoption of AI at your health system or hospital? Patrick McGill, MD MBA, executive vice president and chief transformation officer at Community Health Network says it is essential to have governance in place early in your AI journey. "You need to have the governance in place to make sure that you understand all of the tools that are being used, how the tools are being used, the intended outcome of usage, and how you mitigate bias," McGill says. "Having a governance structure in place from the beginning is helpful." The Indianapolis-based health system has created an executive steering committee to handle AI governance. "The focus of the executive steering committee will include prioritization of projects; implementation and use of policies, procedures, and traditional governing functions that must be put in place; resource allocation; and oversight of the monitoring of AI tools to reduce or eliminate bias and other unintended consequences of AI," McGill says. Read the full HealthLeaders story at https://lnkd.in/ehZYBGwt

2

A few thoughts on a recent HBR piece on “designing incentives” to influence physician behavior. On the one hand, actively engaging physicians to improve performance, examining care delivery expenses broadly (i.e., looking beyond just device cost), and demonstrating good faith efforts to share value are all worthy and underutilized strategies. On the other, the attribution methods described are complex, increase administrative burden and risk, and fail to engender trust. In addition, one glance at Open Payments and the medical literature (e.g., Sayed A et al, JAMA 2024;331:1325) should quickly disabuse any wishful optimism about the potential of shared savings in the current environment. Though well-meaning, the article perpetuates the caricature of physicians as pricey barbarians and doesn’t address industry distortions. A better and more sustainable approach would recognize physicians as indispensable partners and subject matter experts – this is the way to attaining quality outcomes and responsible stewardship.

11

1 Comment

Interesting market opportunities for Pediatric Care. Creating long term opportunities for coordination of care toward outcomes for many pediatric populations.

1