Kurt Tamaru, M.D.

#fraud, #healthcare, #The Wall Street Journal WHAT A SHAME - Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated https://lnkd.in/dRKitYtW 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 like Lee’s, a Wall Street Journal analysis of billions of Medicare records found. 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. Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said. One reason is that insurers can add diagnoses to ones that 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 doctors’ views. ...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. ...Humana disputed the Journal’s calculation that the company had received $2.2 billion in 2021 payments from insurer-driven diagnoses, saying that total didn’t reflect chart reviews that lowered payments by removing diagnoses.

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The Illusion of Efficiency in Healthcare: A Deep Dive into ACA's Impact Remember the argument on the quality and efficiency of healthcare during the ACA debate? This argument led to policy changes in the ACA that facilitated hospitals buying up physician practices and insurance companies owning pharmacies and benefits managers—both industries becoming big in the process. The notion was that by becoming big, both industries could bring in efficiencies by eliminating wasteful expenditures. But what happened? Both industries consolidated their market share and raised prices for the consumer. Hang on, one might argue that while we could not reduce the cost, we have improved the quality, and quality comes with a price. Fair argument, right? Has the quality of care improved? Well, this paper answers that question with a resounding NO. At least in this study, the quality of healthcare—as measured by in-hospital mortality, 30-day mortality, and 30-day readmission rates among a select patient population of a large independent cardiology practice before and after their integration with a large academic health system—did not improve. Another argument used in the ACA debate was that vertical and horizontal integration would reduce the utilization of services such as labs and scans because they would be more easily accessible through electronic health records. Has this argument survived research scrutiny? Again, the answer is NO. This study found no difference in the utilization of services when comparing before and after integration. Funny enough, I asked Google AI, “Does integration of outpatient practices with hospitals improve quality?” The Google AI overview gave me this answer: “Yes, integrating outpatient practices with hospitals generally leads to improved quality of care by facilitating better coordination of patient care, streamlined communication between providers, and access to more comprehensive services across different healthcare settings, ultimately enhancing patient outcomes,” and provided a list of references. All of them were review articles by influencers saying how “it feels good.” None of them referenced how “it felt good.” I hope the L!nk€d!n algo will pass this post in its quality check. What are your thoughts? #Healthcare

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Dr. Jain...THANK YOU for this insight and support for the kind of work I do every day! Building complex geriatrics longitudinal care programs is where I cut my value based teeth! These programs - when structured with attention to detail - can create a profoundly positive impact. A fully integrated program that is carefully facilitated, orchestrated, and navigated WITH a patient quite literally changes lives. As a system we have to shift our thinking and embrace the FACT that cookie cutter medicine is NOT effective as well as the notion that precision medicine is not scalable, replicable or sustainable....because it CAN be. Been there, done that (and continue to do it) and have the results to prove it! At Synergy 3C, THESE are the models we build and have a track record of success! We would love to have a conversation with you about HOW these models can and do work! #complexpopulationhealth #complexgeriatrics #medicareadvantage

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We have to do better than this for both our providers and our patients. Removing documentation burden from providers isn't just good for them, it is good business sense in all the ways that matter...clinical outcomes, patient safety, availability and satisfaction. If this is an area of focus for your organization, our virtual documentation solutions are an effective and cost efficient way to move this needle. Documentation does not have to get in the way of patient care. From the article: The TrendBurden Pulse Survey from AMIA (American Medical Informatics Association)'s 25x5 Task Force was designed to collect data and insights on how clinicians are experiencing documentation burden and charting within electronic health record workflows. This April, AMIA received more than 1,250 responses from healthcare professionals – physicians/surgeons (36%), registered nurses (25%), licensed social workers, educators and others – across 49 states and the District of Columbia. Across all respondents, nearly 75% of respondents said "the time required for documentation impedes patient care," says AMIA.

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AccendoWave - A Pain #Data Company More recently, the federal government has begun using the QIS program and QRS parameters to advance health equity. Federal rules now require all marketplace insurers to adopt a strategy for reducing health disparities and to stratify certain clinical data by race and ethnicity. While state-based marketplaces (SBMs) have authority to supplement these federal minimum QIS and QRS standards with state-specific quality rules, most have hewed closely to the federal default approach. California and Washington are notable exceptions. Each has implemented a customized QIS program and robust data collection standards to identify and reduce racial and ethnic health disparities. Time to Focus on - #Pain not being Believed. A Root Cause Health Equity Problem. A Top 4 Global Health Equity Solution and Top 15 Global Remote Monitoring Company, AccendoWave, benchmarks objective brain wave pain data (specialty, gender, age) and has nine #pain databases: Emergency Department, Maternal Health, Oncology, MSK, Medical Surgical, ICU, #Women, Adults, #Seniors to eliminate bias, improve outcomes and reduce health care costs. If desired, AccendoWave can also create customized pain databases for partners that can be accessed on the Datavant platform.

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“Health care spending growth is expected to outpace that of the gross domestic product (GDP) during the coming decade, resulting in a health share of GDP that reaches 19.7 percent by 2032 (up from 17.3 percent in 2022).” https://lnkd.in/gHmXUWYa

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New Research on Medicare Advantage: 💰 Costly for Taxpayers, 💡 Popular with Enrollees New research published today by University of Southern California researchers (link in comments) finds that Medicare Advantage (MA) – the private alternative to traditional Medicare – costs taxpayers 22% more per member, amounting to $83 billion extra every year. 😲 The researchers claim MA was meant to save money through competition, but loopholes in the payment system have caused overpayments to insurers. Here’s what’s happening: 📊 MA plans are paid more for patients who “seem” sicker, even if they aren’t. This “upcoding” makes plans look costlier than they are. 💰 For every $1 overpaid to insurers, only 50-60 cents goes back to enrollees through lower costs or extra benefits (like dental or vision). 📈 Meanwhile, MA enrollment is skyrocketing, now covering half of all Medicare beneficiaries. Many choose it for added benefits, but switching back to traditional Medicare can be tricky. What’s the fix? 🤔 Reforms like better payment audits, adjusting overestimated benchmarks, or accelerated the adoption of value-based care to ensure MA truly saves money. The goal: protect Medicare’s future while balancing benefits for enrollees. The bottom line: according to these researchers, Medicare Advantage has promise, but without reforms, taxpayers are overpaying. What do you think? 🩺🇺🇸 #MedicareAdvantage #HealthPolicy #HealthcareInnovation

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Main Point of Value-Based Care Value-based care is a healthcare model that ties the amount providers earn to the quality and cost-effectiveness of the care they deliver to patients. Unlike the traditional fee-for-service system where providers are paid for each service rendered regardless of outcome--value-based care rewards providers for improving patient outcomes while keeping costs down.

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Across the healthcare industry, inpatient denial claims are skyrocketing - and inflation is decimating providers’ financial stability. According to a recent report from Becker’s Hospital Review, the final denial rate on inpatient claims increased by a staggering 51% between 2021 and 2023 alone. This surge in denials is concerning for several reasons. Not only does it drain $1.2 billion in revenue that hospitals and health systems rely on to provide care to their communities, but it also means that hospitals are spending more money and resources to appeal these denials. The increase in initial denials on inpatient claims for prior authorization and precertification errors is particularly alarming. These errors rose by 26% from 2021 to 2023, adding to the financial burden faced by healthcare providers. As providers navigate these challenges, companies like No Surprise Bill must advocate for a fairer system that prioritizes patient care over profits. I encourage you to read the full report for more insights into this critical issue - click the link in the comments below to learn more.

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Another real-world study shows patients struggle to take GLP-1 medications. Mayo researchers analyzed EHR and Surescripts data from 8996 patients (BMI>30) who filled a liraglutide or semaglutide prescription and looked at one-year results. Key findings were that only 41% of patients took the drug for at least 9 of the 12 months, and average weight loss across the group was 3.7 percent. Not surprisingly, patients who took the drugs for more months and those who took semaglutide lost more weight. The authors had access to pharmacy fill data, which is helpful. What they didn’t have was the reason why patients didn’t fill their prescription, presumably loss of insurance coverage, supply issues, side effects, or just a change of plans. In the context of much more robust clinical trial results, here’s more evidence GLP-1s aren’t a magic bullet.

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In the last 2 years, $265 BILLION of #healthcare spending is shifting to home-based care models like WelbeHealth and CINQCARE. Enabled and accelerated by #telemedicine, new #remotepatientmonitoring billing codes, and other new technology, #Payers and #healthinsurers are hammering away on expensive hospital stays. “Hospital at home” and “aging in place” models are spreading rapidly, with proof points such as the 38% net savings demonstrated by Brigham and Women’s home hospital pilot study. The big limitation: a million #caregivers are needed by 2030 to meet the demand, but pay is low and turnover is high. Watch how quickly states begin launching caregiver stipend programs in #Medicaid to keep friends, family and neighbors engaged in care at home. Strategic #investment areas I’m watching: ▶️ Companies that train and enable net new supply of caregivers and #communityhealthworkers. ▶️ Software and MSOs to improve #homehealth agencies by increasing efficacy and efficiency ▶️ Platforms that integrate ordering, logistics, and payments Some of the best businesses in the health care industry are focused on avoidable costs, and grabbing crumbs off the big boys’ tables. At $4.7 TRILLION in annual spending, those are big crumbs.

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Advance care planning conversations save money and increase utilization of specialized end-of-life care (hospice and palliative care). On a personal note, I had been speaking with my in-laws about completing an advance directive. At Christmas one year, we had a direct conversation about the Five Wishes document that they had completed. My Father-in-law Gary was very direct and clear in how he spoke about his wishes; no machines. He fiercely did not want to become depended on others. Gary had a heart attack a year later. He was kept alive on a ventilator until my husband could fly in and say goodbye. We were all so grateful to have had that conversation. There was no second-guessing. He was clear in telling us his wishes and so we were clear in honoring them. ACP conversations are VITAL for practitioners and family members to have in order for people to have the ending they want, or hope for. (Gary died before the launch of The Death Deck or we would have also used it to help have these important conversations).

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New #ManattOnHealth Insight by Lora Kim and Nina Punukollu: The Centers for Medicare & Medicaid Services (#CMS) just approved a historic #Medicaid expansion in Arizona, California, New Mexico and Oregon, marking the first time traditional #HealthCare practices will be covered under Medicaid and #CHIP. This landmark decision opens doors to culturally appropriate health care—aimed at tackling longstanding health disparities affecting American Indian and Alaska Native communities. Learn more: https://lnkd.in/ehsvJpMk

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The Critical Need for Accurate Remote Patient Monitoring in Medicare With the rise of remote patient monitoring (RPM), ensuring proper oversight is essential for patient safety and care quality. Recent scrutiny from the Office of Inspector General (OIG) highlights gaps in Medicare's oversight, emphasizing the importance of getting RPM right. Accurate and reliable RPM can improve patient outcomes by providing real-time health data and enabling timely interventions. However, without stringent oversight, the potential for errors and misuse could undermine its benefits, especially for vulnerable populations. For healthcare providers, regulators, and innovators, now is the time to prioritize accountability and precision in RPM systems. Patients' health depends on it. #PatientCare #RemoteMonitoring #HealthcareInnovation #Medicare #HealthTech

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Healthcare Deals and News for Week ending September 20th, 2024: · Cardinal Health (NYSE: CAH) to Acquire Integrated Oncology Network for $1.115 Billion, Expanding Community Oncology Services · Northwest Urgent Care, Subsidiary of Community Health Systems, Inc. (NYSE: CYH), Acquires 10 Arizona Urgent Care Centers from Carbon Health, Expanding Tucson Healthcare Network · Encore Clinical Holdings Corp (Encore Wound Care) Expands Wound Care Services in Northeast Ohio with Acquisition of Ohio Wound Care · CentralReach Acquires Behavior Science Technology Inc., Insight Partners and Arc Capital Development, to Enhance ABA Care with AI-Powered Treatment Fidelity Solutions · Vyne Medical Acquires Extract Systems to Enhance Healthcare Automation and Data Management Capabilities via its Financial Sponsors, Health Catalyst Capital (HCC) and TJC · RLDatix Acquires SocialClimb to Enhance Healthcare Operations with Comprehensive Patient Insights and Reputation Management via Nordic Capital, Pantheon International Plc, Torreal, Resolve Growth Partners, Susquehanna Growth Equity (SGE), TA Associates, and Five Arrows Principal Investments · SubjectWell Acquires Trials24 GmbH via WindRose Health Investors · MedeAnalytics Acquires SubPop Health, Inc., a spinout from Hashed Health, via JLL Partners · Blue Matter Acquires Sam Brown Healthcare Communications., via Baird Capital · Panacea Healthcare Solutions Acquires KA Consulting Services a Division of Panacea via its Financial Sponsors Columbia Pacific Capital Partners and The Firmament Group · Agape Care Group Expands Hospice Services with Acquisition of Select Crossroads Hospice Facilities Across Four States via Audax Private Equity, H.I.G. Capital and Ridgemont Equity Partners Other and Venture News · Xvivo Perfusion Acquires FlowHawk Software Platform to Enhance US Transplant Clinical Workflow Automation Healthtech Solutions Inc. · Candid Health Secures $29M in Series B Funding Led by 8VC, Joined by First Round Capital, BoxGroup, and Y Combinator · Scriptology Acquires RxLive, Accelerating Growth with AI-Driven Medication Management Platform · Fabric Expands Virtual Healthcare Network with Acquisition of TeamHealth VirtualCare For more details on these transactions and more: https://lnkd.in/gqPHCCYU Read our recently released BioAstronautics, (Space Health) white paper on the future of space health. https://lnkd.in/gbvyC5j3 Join our bankers at these events: Sept 25 - 26 HFMA Columbus OH Oct 7-9 - Behavioral Health Business Invest Conference Dallas TX Oct 20- 23 HLTH Las Vegas NV Lawrence, Evans & Co. LLC (LECO) is a leading national healthcare financial advisory firm. We specialize in capital raising, mergers and acquisitions, and restructuring for lower middle market private companies, delivering strategic solutions to maximize value and drive long-term growth across healthcare, technology, and business services.

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The 2025 Vizient Trends Report is out! It highlights trends that will drive success: - Accelerating patient access - Leveraging pharmacy advancements - AI enhancements for decision-making - Optimizing Medicare Advantage strategies

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More in the world of #340B shenanigans. Hospitals claim that if they lose their massive 340B subsidies, they will be forced to cut services to the poor... Well, it turns out that the only hospitals which actually expand services to the poor with 340B funds are public hospitals. Private, nonprofit hospitals show no increase in unprofitable services aimed at the poor (substance abuse, psychiatric and obstetrical services) with 340B participation. Why does this huge financial subsidy go to the institutions and not follow the patients? This strange quirk in the law makes it so large, consolidated health systems can use 340B to pad their revenue without increasing services for the poor. They instead use the proceeds to increase their market share and drive independent practices out of business. Don't fall for the argument that they'd have to cut services. They haven't used the 340B funds to increase them in the first place! Larry Bucshon, M.D. Deborah Williams Lisa Grabert Brian R. Gantwerker, MD, FAANS, FACS Cheerag Upadhyaya, MD, MBA, MSc, FAANS, FACS Michael Wang Joanne Spetz Adam Fein Sanat Dixit MD, MBA, FACS John Paul Kolcun https://lnkd.in/ga54etMy

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