Michael Zgoda, MD, MBA, CPE

🙌🏻 Good. Also if you need help renegotiating these types of agreements 👋🏻 We have over 1.5 million benchmarks (and growing), I would love to show you exactly how to save money on joint contracts.

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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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CMS has a 41 year track record of abuses very specific to the 2621 counties lowest in health care workforce where hospitals have been closed by the hundreds along with countless practices. The new cuts will be a minor impediment to most providers, but it will mean termination or major compromise in more of these counties with 40% of the population in 2010 and growing to 50% by the 2060s as CMS accelerates the decline of what health care remains. The 2621 counties include 37 million rural people (75% consistent in behind) and 90 million urban people (32% fastest growing). These rural and urban populations are both behind in outcomes and drivers of outcomes. This means that CMS micromanagement is costly, burdensome, and discriminatory. There is no value to compromise and terminations of hospitals, practices, team members, jobs, and local leaders. There is no validity of volume to value in what remains of health care services in these counties that have half enough of all basic health access specialties, access barriers, underutilization, and inappropriate utilization. The CMS one size fits all designs have very specifically caused harm to vulnerable populations. heir designs have not had supportive or beneficent intent. They reveal their true colors by cost cutting again and again. They fail to properly study the consequences or listen to critique. Therefore they cannot give informed consent to legislators, leaders, and people left behind. They violate the Belmont Principles and must be held accountable - same as physicians and human subject researchers. The string of steady abuses across DRG, RBRVS, manage care, Readmissions, Star Ratings, and value based designs continues. Millions of excess deaths are by design based on the same calculations used in African American populations and the 2621 counties have 2.7 times more people. CMS plans pay less than cost of delivery and pay 15 - 30% less in these counties. The better employers with their better paying private plans that bail out CMS deficits by design, are missing from the 2621 counties. Even worst the government, health care, and education jobs that did have better insurance, are being cut or centralized away. Only Hill Burton 1946 to 1997 and the first decade of Medicare and Medicaid with inflation related higher payments have helped these counties. Since the 1980s and in reaction to runaway health care costs engineered by those doing best, there have been cost cutting designs that abuse those politically weaker, distant, and poorly understood - the most. They have never spared basic health access or most Americans most behind who will not be writing letters

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Mark Your Calendar: December 17th! Join me at 10:00 AM PST | 1:00 PM EST for the Medicare Quarterly Updates Webinar - 4th Quarter hosted by McVey Seminars. Stay informed with the latest Medicare updates! Register today: https://lnkd.in/gmgzbjSg Let’s navigate these updates together! #McVeySeminars #TerryTuesday

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It is not a positive step 1. When physicians and NP and PA delivering the care and their teams are selected out for harm after years of marginalization 2. When basic health access is harmed by the continued 41 years of cost cutting the most convenient and lazy way possible - across the board 3. When vulnerable populations continue to grow past half of the US population and their remaining providers are not spared from cuts, compromises, meaningless micromanagement, lower payments, and penalties because of the populations that they serve 4. There is nothing that we should be proud of for 40 years of lazy ineffective designs That have failed to stop the horror of twice too much health spending That defeat budgets at all levels of the ability to invest in Americans That have added discrimination and worsening of disparities by design.

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Interesting what comes to light when you “throw some data on it.” Metrics like this have unintended consequences. Queuing theory and it’s application have always made more intuitive sense to me…Queuing theory considers factors like arrival rates, service rates, queue length, and waiting time to predict system performance and find the most efficient configurations. How medicine can be so innovative in some areas and so arcane in others baffles me. But as long as we pay hospital leaders to achieve short-term metrics for bonus money, we will stifle innovation. You get what you pay for…

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The PDP market is something that we at Healthsperien LLC have been closely watching and advocating around. The demo and the $15 premium waiver are laudable adjustments to a marketplace that is facing a perfect storm of financial pressures. However, more work has to be done around other aspects of the Part D program - namely Star Ratings - as applied to particular subsets of the Part D program. Specifically, those benchmark plans with high % of LIS beneficiaries (~20% based on the data we've looked at). Those plans have extreme difficulty satisfying minimum Stars thresholds and while financial amelioration is necessary, it is not sufficient for an all around response to the woes of that particular market subset.

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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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Another important position statement from Association of Healthcare Value Analysis Professionals (AHVAP). As value analysis evolves, it is vitally important to ensure that those who are entrusted with the process understand what is expected of them in terms of professionalism. Please feel free to share this important document.

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Very important article on the secondary impacts of the pandemic on our healthcare system. They are not good!!     Hospital COVID-19 Burden and Adverse Event Rates "After risk adjustment, the relative risk (RR) for AEs among patients admitted during weeks with high compared with low COVID-19 burden for all patients was 1.23 (95% CI, 1.09-1.39; P < .001), with similar results seen in the cohorts with (RR, 1.33; 95% CI, 1.03-1.71; P = .03) and without (RR, 1.23; 95% CI, 1.08-1.39; P = .002) COVID-19 individually."   "Conclusions and Relevance In this cohort study of hospital admissions among Medicare patients during the COVID-19 pandemic, greater hospital COVID-19 burden was associated with an increased risk of in-hospital AEs among both patients with and without COVID-19. These results illustrate the need for greater hospital resilience and surge capacity to prevent declines in patient safety during surges in demand." Jama Network: https://lnkd.in/e23HcJkm  

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Medicare Advantage enrollment is on the rise, with 54% of the total federal Medicare expenditures (excluding premiums) allocated to MA participants in 2023.   MA plans need accurate risk adjustment to best support their growing populations, and ensure appropriate payments. This is a good overview on how to prepare for #RADV audits. https://lnkd.in/e-y3sQSR #MedicareAdvantage

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We are now in the public comment period for the next round of cuts to the Medicare Provider Fee Schedule. The work that physicians and other clinicians do continues to be discounted as part of the goal of budget neutrality. Dr Rob Zipper explains the unforeseen consequence of these cuts and the lack of an inflation index which is approximately a 25% reduction physician salaries over the last 20 years. Many physicians and group practices have looked to hospitals and health systems to make up for part of that gap, however, that has been difficult in recent years. In a country where we want to continue to recruit the best in the brightest into healthcare careers, this problem needs to be addressed. Last year there was proposed legislation to add a Medicare inflation index to the clinician payment structure, an approach already used for hospitals. That didn’t pass so we are once again facing additional cuts without any inflation adjustments. The legislature needs to evaluate the opportunity to eliminate additional cuts in payment to physicians for clinical care of patients and to tie the Medicare Provider Fee Schedule to an appropriate inflation index. Listen to this podcasr for additional insights.

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Join Kina L. White, DrPH, MHSA, FACHE, and me next Thursday, November 7, for a webinar, Getting Ready for the CMS Age-Friendly Measure. The #webinar is free for Mississippi Hospital Association members and $100 for non-members. We will crosswalk the requirements for becoming an #AgeFriendly Health System with the requirements of the new CMS structural measure that goes into effect on January 1, 2025. The Age-Friendly Hospital Measure assesses a hospital's commitment to providing age-friendly care. It consists of five domains: - Eliciting Patient Healthcare Goals - Responsible Medication Management - Frailty Screening and Intervention (Mobility, Mentation, and Malnutrition) - Social Vulnerability (Social Isolation, Economic Insecurity, Ageism, Limited Access to Healthcare, Caregiver Stress, Elder Abuse) - Addressing Hospital Culture and Leadership for Age-Friendly Care Hospitals receive one point for each domain they meet, with a total score ranging from zero to five. We will also cover how to incorporate age-friendly care into your #healthequity work. In addition to those over 65 being a group that experiences health disparities, there are also more disparities within that larger group. For example, Black and Hispanic older adults are more likely to report wanting their healthcare providers to spend more time discussing what matters to their health and well-being. And rural older adults often face challenges in accessing specialized geriatric services. We will share tools and resources available in Mississippi and nationally. For those registered, a recording and the slide deck will be shared. I hope to see you there! Register here: https://lnkd.in/g8j64XZb

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Health insurance Prior authorization rationing of physician recommended preventive, medical, surgical and palliative care occurs over 1 million times a day in America. Medicare Advantage insurance plans ration care causing delays, changes and abandonment of physicians recommended care 100’s of thousands of times a day devastating patient health and physician workflow. #quadrupleaim #vbc #valuebasedcare

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The Medicare Advantage star ratings system is designed to evaluate the quality of Medicare Advantage plans. These ratings range from 1 to 5 stars, with 5 being the highest, and are based on several factors, including customer service, member satisfaction, and health outcomes. Higher star ratings lead to better reimbursement rates from CMS and can help attract more enrollees. UnitedHealthcare’s lawsuit claims that its downgrade was based on a single customer interaction, which could negatively affect its reimbursement and market competitiveness during the open enrollment period https://lnkd.in/erKQy7Ge #MedicareAdvantage #StarRatings #UnitedHealthcare #CMS #HealthcareLawsuit #HealthInsurance #MedicareNews #OpenEnrollment #HealthcareUpdates #MedicareAdvantagePlans #InsuranceRatings #HealthcareFinance #PatientCare #MedicareReform

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https://lnkd.in/gG94Ttvj WHY DOES THIS EVEN EXIST? Few examples crystallize the inanity of fee-for-service payer model better than this story from Becker’s. Not only is the ASC at risk for not getting paid for what they did, the process is ginning up the ASC’s overhead expenses to submit documentation to justify what the payer is declining. So the ASC needs higher fees to supply the documentation for the procedure they aren’t getting paid for. This is a destructive positive feedback loop — with very negative consequences for employer-sponsored healthplans and covered members. In nature, a tornado is a destructive positive feedback loop. It destroys until it consumes its resources and finally gives out, leaving behind a changed landscape. When this payment loop finally fails and changes the landscape, the member and plan no longer have access to care that’s less expensive and more convenient than hospital care. Why does this problem even exist? Because of an obsolete payment model that is so firmly entrenched by those it enriches. Bundled payments for scheduled episodes of care from the simple (a lab test) to the complex (heart valve replacement) give the healthplan a good deal, the provider a reliable, planned payment with far less overhead expense and the covered member a low or ideally $0 out-of-pocket. An employer will pay for a lot of predictable healthcare. CT scans, knee replacement, lab tests will all happen. You may not be able to predict who will need services but you can predict they will happen. Why not just directly contract for those predicatable services and cut out all the unnecessary chaff? It’s not rocket science (or meteorology). ZERO.health Scott Conard, MD Keith Smith Nadora Healthcare

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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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Not fair and balanced Advertorial for Private Equity A total conflict of interest Immoral to destroy healthcare for opportunity to work for companies that profit on ultimately destroying USA 🇺🇸 healthcare as we knew it. People that worked for CMS should be banned from working in industries that profited from the decisions and have connections for future decisions to destroy the healthcare fabric No discussion of the negatives only the positives Consolidation leads to fewer choices for patients The cons for patients outweigh the pros for the investors. Profits over care ultimately leads to rationing of the care that is not profitable Management of PE selects doctors to interface that benefit from a hard line approach over providers that see quality issues and patient safety as important Cheerleaders 📣 for the profiteers

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