Lisa Shock, DrPH,MHS,PA-C

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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Nearly all Medicaid health plans participate in #ValueBasedCare initiatives, but just over half of those plans cite there are still barriers to adopting the model according to the Institute for Medicaid Innovation’s annual managed care survey. Survey findings noted the following challenges in implementing value-based care models: ✅ Provider readiness or willingness 🧑‍⚕️ Staff capacity 📊 Lack of sufficient/complete data 💻 Information technology system preparedness With the right resources and education, value-based care can have a positive impact on quality of care and patient outcomes. However, we must equip providers with the #data, infrastructure and talent to support value-based models. I’m encouraged by the opportunity these findings present to continue building awareness, and I’m hopeful we can continue to find ways to ease the transition from the fee-for-service model.

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Our own Nathan Paulsen, MBA, who joined Oshi recently from a national payer, wrote a great article about value-based specialty care. Definitely worth reading in the post & link below. The main question underlying the transition to #valuebasedcare outside of the traditional primary care, full-risk for whole populations and government innovation models is this: Do commercial health plans have both the incentives and the resources to execute new ways of contracting for specialties that require more nuanced attribution of risk? Even when they acknowledge these specialties are driving the majority of the cost? Anyone seeing health plans that are leaning in? Anyone experiencing issues where plans talk a big game about VBC but then don't really have resources to do the actuarial, data and contracting work? I'd be curious to hear people's thoughts in the comments below. #specialtycare #AHIP2024

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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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🌍 Join The Joint Commission next month at Total Health 2024 for a panel discussion on advancing health equity goals through value-based programs, focusing on addressing healthcare disparities, adopting innovative care delivery models, and establishing community partnerships. Register today: https://bit.ly/3SqGGNn Full Details: Where? Radisson Blu Aqua Hotel, Chicago, IL  When? October 8th, 3:10-3:50pm  Who? James Merlino, MD, EVP & Chief Innovation Officer, The Joint Commission  What? Panel: Advancing health equity goals via value-based programs - Acknowledge healthcare disparities among demographic groups to integrate health equity principles into value-based care programs, ensuring equitable access and tailored interventions for vulnerable populations. - Adopt innovative care delivery models, such as mobile health clinics, telemedicine, and community health worker programs, to expand access to care and reach underserved populations in geographically isolated or medically underserved areas. - Establish partnerships with community-based organizations, faith-based groups, and social service agencies to leverage existing resources, networks, and expertise in addressing SDoH and reducing disparities in healthcare access and outcomes. Interested in attending? Register today with a Business-level pass and receive a FREE VIP UPGRADE ($500 value) - offer ends EOD today! #TotalHealth24

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HEALTH CARE TRANSFORMATION SUMMIT: June 10-11 Explore the present and future of health care at our Inaugural Health Care Transformation Summit. This will be a comprehensive gathering of Indiana’s largest health care stakeholders to foster ideas and solutions to improve health care outcomes, increase access, and decrease costs for patients, providers and employers. Attendees will gain perspective on the short- and long-term evolution of the health care industry, including the impacts on today’s workplace. This is a unique opportunity to understand where we are today and where we’re going in the future. Panel topics include: - Employer Strategies - Obesity in the Workplace - Ensuring Access to Pharmacy Benefits and Supply Chain Security - Innovative Models of Health Care - Rural Health Care and the Role of Hospitals in the Future of Health Care - Role of Insurance Companies in the Future of Health Care - Emerging Models and Technology in Health Care - Price Transparency - Preventative Care and Precision Medications Presented by CVS Health. Register: https://lnkd.in/gAkVkDQ4 #healthcare #healthcaretransformation #healthcaresummit

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HEALTH CARE TRANSFORMATION SUMMIT: June 10-11 Explore the present and future of health care at our Inaugural Health Care Transformation Summit. This will be a comprehensive gathering of Indiana’s largest health care stakeholders to foster ideas and solutions to improve health care outcomes, increase access, and decrease costs for patients, providers and employers. Attendees will gain perspective on the short- and long-term evolution of the health care industry, including the impacts on today’s workplace. This is a unique opportunity to understand where we are today and where we’re going in the future. Panel topics include: - Employer Strategies - Obesity in the Workplace - Ensuring Access to Pharmacy Benefits and Supply Chain Security - Innovative Models of Health Care - Rural Health Care and the Role of Hospitals in the Future of Health Care - Role of Insurance Companies in the Future of Health Care - Emerging Models and Technology in Health Care - Price Transparency - Preventative Care and Precision Medications Presented by CVS Health. Register: https://lnkd.in/g7CesAPv #healthcare #healthcaretransformation

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The OIG highlighted in its 2024 Semiannual report it expects to recover nearly $3 billion, has taken 712 enforcement actions, and has excluded 1,795 individuals and entities from the federal health care program. The OIG's oversight work conducted during the reporting period, focusing on the most significant challenges facing the HHS, has highlighted a key area: Third-party liability (TPL). State Medicaid agencies continue to struggle to meet TPL requirements, which are crucial for ensuring that Medicaid is the last resort payer. The OIG has pinpointed various obstacles, such as difficulty obtaining timely and dependable coverage information from third parties. Outsourcing these workflows and allowing an expert team to assist you in overcoming these challenges can ensure that your State Medicaid agency meets TPL requirements. 🚫 Don't Let TPL Challenges Hold You Back Contact me anytime to learn more about our solution and how we can help your State Medicaid agency thrive. Schedule some time with me here: https://lnkd.in/g76sD7dC By partnering, you: 📝 Minimize administrative burdens and costs related to managing third-party liabilities. Most vendor agreement conditions only charge if revenue is found and collected.  💰 Improve the accuracy and timeliness of payments or, in some cases, collect on accounts receivable subject to write off. ✍ Reduce recoupment payment adjustments and interrupt revenue forecast and budget planning. 📊 Tap into advanced data analytics to detect and prevent errors and discrepancies. 👨‍⚖️ Receive expert guidance and support to comply with OIG recommendations and CMS regulations. 🏫 Access custom training and education to empower your staff to confidently manage third-party liabilities. #TPL #ThirdPartyLiabilityManagement #MedicaidLiabilityRequirements #HealthcareFinance #PayerOfLastResort #MedicaidCompliance #HealthcareRegulations #ThirdPartyPayments #MedicaidAdministration #HealthcarePolicy #GovernmentPrograms #OIG #Healthcarenews Read the full article here: https://lnkd.in/gPBiMMeE

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Year after year, the Centers for Medicare & Medicaid Services (CMS) has made significant cuts to the Medicare home health program. 𝗗𝗲𝘀𝗽𝗶𝘁𝗲 𝘁𝗵𝗲 𝘀𝗲𝗿𝗶𝗼𝘂𝘀 𝗶𝗺𝗽𝗮𝗰𝘁 𝗰𝘂𝘁𝘀 𝗵𝗮𝘃𝗲 𝗼𝗻 𝗽𝗮𝘁𝗶𝗲𝗻𝘁 𝗮𝗰𝗰𝗲𝘀𝘀, 𝘁𝗵𝗲 𝗮𝗴𝗲𝗻𝗰𝘆 𝗷𝘂𝘀𝘁 𝗽𝗿𝗼𝗽𝗼𝘀𝗲𝗱 𝘆𝗲𝘁 𝗮𝗻𝗼𝘁𝗵𝗲𝗿 𝗿𝗼𝘂𝗻𝗱 𝗼𝗳 𝗰𝘂𝘁𝘀 𝗳𝗼𝗿 𝟮𝟬𝟮𝟱. These cuts make it more and more difficult for home health clinicians to meet the growing demands of an increasingly complex patient population. Further, these cuts directly impact the ability to recruit and retain nurses, therapists, and clinical staff to provide high quality services to our patients. In the newly released Home Health Prospective Payment System Proposed Rule for Calendar Year 2025, CMS has proposed a permanent adjustment of -4.067% to the 2025 home health base payment rate. And while CMS chose not to implement the temporary “clawback” cuts for 2025, additional cuts to home health loom in the future. For patients, the transition home following a hospitalization is challenging enough, and home health cuts will only make it harder. 𝗪𝗲 𝗻𝗲𝗲𝗱 𝘆𝗼𝘂𝗿 𝘃𝗼𝗶𝗰𝗲 𝘁𝗼𝗱𝗮𝘆 𝘁𝗼 𝗴𝗲𝘁 𝘁𝗵𝗶𝘀 𝗹𝗲𝗴𝗶𝘀𝗹𝗮𝘁𝗶𝗼𝗻 𝗽𝗮𝘀𝘀𝗲𝗱. It is critical that the home health community is heard! 𝗣𝗹𝗲𝗮𝘀𝗲 𝘀𝗲𝗻𝗱 𝗮𝗻 𝗲𝗺𝗮𝗶𝗹 𝘁𝗼 𝘆𝗼𝘂𝗿 𝗹𝗮𝘄𝗺𝗮𝗸𝗲𝗿𝘀 𝘁𝗼𝗱𝗮𝘆 𝘂𝗿𝗴𝗶𝗻𝗴 𝘁𝗵𝗲𝗺 𝘁𝗼 𝗰𝗼-𝘀𝗽𝗼𝗻𝘀𝗼𝗿 𝗦. 𝟮𝟭𝟯𝟳/𝗛.𝗥. 𝟱𝟭𝟱𝟵. 𝗧𝗮𝗸𝗲 𝗔𝗰𝘁𝗶𝗼𝗻: https://lnkd.in/gwb87ShY #homehealth #medicare #inhomecare #healthcare

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Calling all my hospital & health system leaders - I'm having a discussion with some fantastic, knowledgeable experts (Rick Goddard and Michael Englehart who have extensive experience in the health system landscape. This upcoming Tuesday 9/24, we're chatting in an open format on dynamics affecting hospitals & health system transformation. Sign up here: https://lu.ma/1pybjvuo Come with your questions, but here are some topics we plan to cover! • Proven, tactical strategies for health system leaders on where opportunities lie to diversify revenue • Provider-sponsored health plans: losing steam or an effective strategy for the future? • Health system outlook for the rest of 2024 and 2025 (election expectations, M&A environment, etc.) • How headwinds in Medicare Advantage have affected value-based care • Shifting health system mindsets in response to payor vertical integration • & audience Q&A throughout It's going to be a great conversation and I'm looking forward to it!

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In our latest blog, Sarabeth Zemel discusses the support for utilizing Community Care Hubs in states' #Medicaid 1115 waivers as they work to address health related social needs (#HRSNs). Read more about the innovative strategies that states are implementing here: https://lnkd.in/g_xXDNQU #1115Waiver #NorthCarolina #NYS #CalAIM

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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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Primary care is the backbone of a strong health care system. As such, state Medicaid programs are testing policies to strengthen primary care, including new payment approaches. A new primer from Center for Health Care Strategies explores six key design choices that state #Medicaid programs need to make when developing or refining a population-based payment (PBP) model and the implications of these choices, including impacts on health equity for patients and providers. PBP models seek to move away from volume-based, fee-for-service payments and toward predictable “budgets” that support population health management, flexible service delivery, and financial stability for participating providers and the states implementing these models.

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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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😳Humana faces a significant challenge following the release of preliminary 2025 Medicare Advantage (MA) Star Ratings data from CMS. Only 25% of its MA members are now enrolled in plans rated 4 stars or higher, a steep decline from 94% in 2024. 👉🏻The drop was driven primarily by the performance of contract H5216, which covers nearly half of Humana’s MA members, including over 90% of its Group MA plans, and saw its rating fall from 4.5 to 3.5 stars. 💴This will impact quality bonus payments in 2026. Humana is actively appealing some results and working to improve operating discipline to regain its industry-leading position. 🧘Key initiatives will focus on member engagement, customer experience, and technology enhancements to drive long-term value. Medicare Advantage open enrollment kicks off 10/15 and goes until 12/7. STAR ratings expected to be released to the public around 10/10! 📉Down 22% in premarket! https://lnkd.in/gUTT84tR

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Purchased services are vital to healthcare, but they can also become financial drains if not managed properly. A mature purchased services strategy includes insight into all expenses, reduction in unnecessary variation, and prioritized patient care, outcomes, and experience. By focusing on these areas, health systems can lower costs, improve clinical care, and enhance patient experiences. Learn more in Advantus Health Partners article about how to create a mature purchased services strategy: https://lnkd.in/g4UwCjCW #HealthcareSupplyChain #ValueBasedCare #SupplyChainManagement

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