Patrick McGill, MD MBA

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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Challenges and Solutions for Inpatient Capacity Management - HIT Consultant Title: Challenges and Solutions for Inpatient Capacity Management #CriticalChallenges In a recent report on inpatient capacity management, several critical challenges were identified. These challenges include inefficient patient flow, lack of real-time data, and inadequate communication among healthcare teams. #InefficientPatientFlow One of the major challenges in inpatient capacity management is inefficient patient flow. This can lead to bottlenecks in the system, increased wait times, and decreased patient satisfaction. Healthcare IT solutions can help streamline patient flow and optimize resource utilization. #LackofRealTimeData Another challenge highlighted in the report is the lack of real-time data. Without access to up-to-date information on bed availability, staffing levels, and patient status, healthcare providers may struggle ai.mediformatica.com #health #management #report #staffing #discharge #healthsystems #healthcare #leantaas #insights #provider #staffingshortages #aipowered #digitalhealth #healthit #healthtech #healthcaretechnology @MediFormatica (https://buff.ly/4dv4UyJ)

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well worth the read if you are in managed healthcare.

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📢 Webinar Invitation for Health Plan Leaders From Data Overload to Actionable Intelligence: Lowering Barriers to CDI Implementation 🗓️ November 4, 2024, 11 AM PST   In a healthcare landscape driven by data, Health Plans face complex barriers to Clinical Data Integration (CDI) that can hinder quality improvement, resource management, and patient outcomes. Join Thameem Ansari(CTO) and Nikita Ravindran (Product Manager) as they address these challenges and provide strategies for Health Plan executives:   🌐 Data Overload: With patient information dispersed across EHRs, lab results, claims, and surveys, executives often grapple with identifying actionable data insights. This webinar will outline how to streamline data to unlock critical intelligence and drive efficiency.   🔍 Inconsistent Data: Non-standardized data complicates analysis and decision-making, impacting everything from reporting accuracy to reimbursement processes. Learn approaches to data standardization that enhance data reliability and provide a consistent foundation for strategic planning.   📊 Fragmented Sources: Integrating patient data from multiple sources remains a significant obstacle for implementing effective CDI. Our speakers will discuss integration techniques that support cohesive patient records, enabling coordinated care and a clear view of health trends.   During the session, you’ll gain actionable insights on:   ✅ Leveraging automation to reduce manual tasks, freeing teams to focus on high-value analysis. ✅ Applying data mining techniques to reveal trends in health outcomes, disparities, and utilization—guiding targeted interventions and proactive planning. ✅ Embedding CDI initiatives seamlessly into your operational goals for lasting impact.   💡 Join us to explore how to overcome these CDI barriers and turn raw data into valuable intelligence that strengthens healthcare delivery and elevates member experience. This is a must-attend for executives looking to maximize the impact of their data.   👉 Secure your spot and transform your approach to Clinical Data Integration today! https://lnkd.in/ex7M-CWZ #healthchain #clinicaldata #healthplans #payers #ehr #patientoutcomes #healthcarewebinars

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Leaders from UPMC and Abridge discuss central framework guiding #AI implementation for healthcare at the #TopofMind Digital Health Summit. The core principles for implementing this technology focus on empowering healthcare professionals, enhancing the patient experience, and facilitating more informed healthcare dialogues. 

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"Gen AI 'mission-creep' is the biggest health IT and RCM threat I see right now," said Mark Townsend, MD, chief clinical innovation officer at Cincinnati-based Bon Secours Mercy Health. "Don't get me wrong, I believe in the potential of generative AI to help us work smarter and not harder. We are working hard to create new technology using generative AI, we are selectively investing in Gen AI, and Gen AI is not a panacea for patient care or for operational performance." "The mission-creep of gen AI is to oversell its potential and under-deliver on its performance, which absolutely requires a human being in the loop to validate every output," said Dr. Townsend. "Said differently, challenging ourselves to truly quantify the value of gen AI tools is a tall order at this point." https://lnkd.in/euaYzMD6

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☝ Don't Miss the Application Deadlines for the ACO Primary Care Flex Model! CMS is accepting applications for the ACOs Primary Care Flex Model until August 1, 2024. Interested organizations must apply as new or renewing ACOs to the Medicare Shared Savings Program (MSSP) by June 17, 2024. The ACO PC Flex Model will launch on January 1, 2025, and run for five years. Low-revenue ACOs participating in the Shared Savings Program can apply to the ACO PC Flex Model. This innovative model aims to increase the number of low-revenue ACOs and enhance primary care payment through a Prospective Primary Care Payment (PPCP) option, shifting payment from fee-for-service to a predictable, monthly payment. 💲 Enhance primary care payment and innovative care delivery  📉 Narrow Disparities in health care outcomes  🔻Reduce program expenditures while preserving the quality of care  💪 Strengthen participation incentives for new and low-revenue ACOs 💰 Base Rate and Payment Enhancements  💴 One-time Advanced Shared Savings Payment Health Equity Strategy to drive accountable care and advance health equity #ACOPrimaryCareFlexModel #HealthcareInnovation #PrimaryCare #AccountableCare #Medicare #HealthEquity #SustainableHealthcare #ValueBasedCare #VBC #RiskAdjustment #PPCP #SharedSavings #CMS https://lnkd.in/gmiKZsHM

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The HCAHPS Survey is evolving, and your strategy needs to keep up. NRC Health's latest article explains the new changes and our CAHPS Insider Live webcast offers actionable tips. Check them out here: https://bit.ly/4euy4yB #PatientExperience #NRCHealth #HealthcareInnovation

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CMS Staffing Rule Key Points: https://lnkd.in/dgVZUxQa 1. HPRD for RNs is 0.55 and for Nurse Aides is 2.45 2. In addition, facilities must include an additional 0.48 HPRD using any combination of nursing staff, (LPNs/LVNs, RN's, NA's). 3. An RN will be required on site 24/7. 4. CMS now requires that a good faith effort be made to support hiring and recruitment, and stresses the need to have contingency planning in place. Apploi can help. :-) 5. The rule will be implemented in phases: Staffing Plan/Facility Assessment for all- 90 days Non-Rural Facilities: 24/7 RN & 3.48 HPRD- 2 years RN 0.55 HPRD & NA 2.45 HPRD- 3 years Rural Facilities: 24/7 RN & 3.48 HPRD- 3 years RN 0.55 HPRD & NA 2.45 HPRD- 5 years

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A question often asked by #healthsystemleaders is what will be required for future success. Responses from some of Kaufman Hall’s smartest consultants are featured in this new blog from Ken Kaufman. One common element: The need to make and stick with really hard decisions, which will require leadership initiative and courage at the very highest level. #healthcaremanagement https://lnkd.in/gsAJQqPB

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Implementing an electronic health record (EHR) or migrating to a new one is a complex process. It requires you to keep track of timelines and stay on budget – all while keeping clinicians happy and not interrupting patient care. In its latest report, Gartner® notes that when implementing a new EHR “healthcare provider CIOs can avoid setbacks and position for success by undertaking an organizational readiness assessment and mitigating risks during the strategy and planning phase.” Access the complimentary Gartner® report, Gauge Readiness and Mitigate Risk to Succeed in EHR Implementations, to learn more. Read the report: https://bit.ly/3KCgZVY #EHR #EHRmigration #EMR #EMRmigration #healthcare #interoperability #digitalhealthenablement

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Today we want to share the unpredictability of Prior Auths. can have on not only the patient outcome, but also the unneeded complications it brings upon physicians and their clinics. From a peer reviewed article in the American Medical Association (https://lnkd.in/ggER4Y2H) illustrates the various unnecessary difficulties the arise from prior auths. Just one example of these difficulties is forcing tough decisions on both the patient and the doctor that the best treatment solution might not be one the insurance will pay for, but would instead have to go for a more cost effective option to reduce the payout of the provider. This is just one of the many goals that Hidalga Technologies aims to fix. We are making this complicated process more intuitive and seamless for the clinics that have to deal with these issues everyday. It is far from an easy process but with consistent dedication we know we have the team to succeed. #PatientAdvocacy #HealthTech #PatientCare

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Providers and health systems implementing innovative models are rewarded for ensuring #RightCareRightTimeRightSetting. One example is from Health Care Transformation Task Force member, Trinity Health’s MediGold Medicare Advantage a #HealthCareInnovation that results in better patient outcomes. Learn more about the MediGold total cost of care payment model and then Take Action and ask Congress to advance patient-first models: https://lnkd.in/g58BUfDb

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Complaints, Appeals, and Grievances (CAG) Software – GHIT Digital POV   What is Appeals and Grievances (ANG)? Appeals and Grievances (ANG) refer to the processes through which members of health plans or patients voice concerns about their healthcare services, claims, or administrative decisions. These mechanisms are critical to ensuring compliance, transparency, and member satisfaction. ·        Grievances: A formal complaint made by a member about non-claim-related issues, such as poor service, delayed responses, or inadequate care. Example: A patient complains about long wait times for approval of a pre-authorization request. Appeals: A request by a member or provider to review and overturn a denied claim or service. Example: A patient files an appeal to get coverage for a procedure that their health plan initially denied. What is Complaint, Appeals, and Grievances (CAG)? CAG expands the scope by explicitly incorporating complaints into the workflow, distinguishing them from grievances. This is more commonly adopted in systems where complaint handling is segregated as a lower-threshold concern. Click the link below to read the complete POV or reach out to us for ANG / CAG Software Demo Monika Vashishtha (MBA, PMP, ITIL) [email protected] 646.734.6482 https://lnkd.in/ef5UzY9Q

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An Outpatient Clinical Documentation Improvement (CDI) program offers substantial advantages to healthcare organizations by elevating patient care and operational efficiency. By integrating risk stratification with chronic conditions, enhancing quality measures, addressing social determinants of health, and establishing a collaborative team empowered by technology, such strategic initiatives result in improved patient outcomes and streamlined operations.

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HIMSSCast: New analytics strategies for patient-centric pop health - Healthcare IT news Title: HIMSSCast: New Analytics Strategies for Patient-Centric Pop Health #Introduction: In this HIMSSCast episode, experts discuss the importance of analytics in patient-centric population health management. #The Role of Analytics in Healthcare: Analytics play a crucial role in identifying trends and patterns in patient data to improve outcomes and reduce costs. #Challenges in Implementing Analytics: Healthcare organizations face challenges in implementing analytics, including data integration and interoperability issues. #Patient-Centric Population Health Management: Patient-centric population health management focuses on personalized care plans and proactive interventions to improve patient outcomes. #Strategies for Successful Analytics Implementation: Experts share strategies for successful analytics implementation, including data governance, stakeholder engagement, and continuous improvement. #Key Takeaways ai.mediformatica.com #health #data #analytics #patients #populationhealth #provider #clinical #healthcare #management #this #workflows #clinicalworkflows #digitalhealth #healthit #healthtech #healthcaretechnology @MediFormatica (https://buff.ly/4aNPSTq)

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CVS Health's CFO made a striking confession: "The goal next year is margin over membership". He then explicitly acknowledged the potential loss of up to 10% of their Medicare members to bolster financial margins. What does this mean? In plain terms, one of America's largest healthcare giants, with projected annual revenues nearing $360 billion (still 10% more than last year), is considering reducing its patient base—yes, **patients** (aka members)—under its #MedicareAdvantage plans. This decision comes as a result of growing "utilization pressures"- a payer euphemism indicating that more people are seeking the care they desperately need. And what were those "utilization pressures"? Increased outpatient services, outpatient pharmacy, and behavioral mental health services (healthcare). Big Picture: CVS Health isn’t just any company. It's a behemoth with sprawling operations, including Aetna, a CVS Health Company (a major insurer), CVS Caremark (a leading pharmacy benefit manager), and a vast healthcare workforce through CVS MinuteClinic and Oak Street Health. Despite these extensive resources and their near-monopolistic vertical in the healthcare industry, the focus turns to profits over patients (aka margins over members). The Problem: Incentives. Medicare Advantage insurers and administrators love the upfront capital from Centers for Medicare & Medicaid Services (aka taxpayers), but really dislike it when patients actually need to use their services (which drains their capital) or CMS cuts their reimbursement due to quality concerns. To maintain profitability, they have three options: 1) shed members or 2) make it even more difficulty for patients to use services or 3) all of the above. And here's the problem, all options are bad for patients. Folks, it's beyond time to question the incentives embedded within our profit-drive health insurance system and in Medicare Advantage. We have to critically evaluate how business decisions by CVS (or United Healthcare or Humana) ultimately affect patient outcomes and #provider practice. To be clear, margins are necessary because it's true "no margin, no mission", but when a company can openly prioritize margins with potential repercussions for vulnerable, senior populations, it highlights the profound misalignments between healthcare needs and business strategies. #Healthcare #CVS #MedicareAdvantage #BusinessEthics #PatientCare ABIG Health Matthew Raffa MBA Meroka UNC Kenan-Flagler Business School MBA@UNC ESCP Business School

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Health Data News Roundup: Rising Inpatient Hospital Days for Medicare Advantage Enrollees; ACO Models Can Support Patient Engagement; and Health Data Access #MAPlans #HealthData #Payers #HealthPayers https://bit.ly/3WrkTpU

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Great commentary and details to be considered from post by Deborah Williams Too few probably understand what you've posted, the other major part of the problem. Commercial insured populations (employers & employees) pay the price for government policy failures that represent major hits on company bottom lines or lead to more individual bankruptcies today. #employeebenefits #employers #commerialinsurance #epcouncil.org

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