Robert Groves, MD

🚀 Transform Your Hospital with the CDI MasterClass! 🚀 Are you ready to elevate your hospital's Clinical Documentation Integrity (CDI) practices? Join the ultimate resource for adult acute inpatient care teams, including physicians, CDI specialists, coders, and all stakeholders! ☀️ What We Offer: Unlock a year-long subscription to 50 engaging 30-minute on-demand webinars, rolled out every week! These sessions are designed to ensure that all team members are on the same page while revolutionizing your approach to CDI. Regardless of your shift, take a moment to enhance your skills and knowledge -- just log in and learn at your convenience throughout the contract year! 🏥 Why Choose the CDI MasterClass? The CDI MasterClass program is tailored not only for CDI specialists but also for all stakeholders involved in the process, including medical staff, coders, the CDI team, quality assurance, utlization/case management, appeals/denials management, risk management and compliance. The success of a CDI program relies on collaboration and cohesive efforts among all these groups, as operating in silos rarely leads to effective outcomes. Our comprehensive curriculum empowers your teams to adopt a proactive approach to CDI, leading to: - Improved patient care - Optimized coding accuracy - Enhanced net financial outcomes for your organization 👌🏽 Don’t Miss This Opportunity! Transform your hospital's operations and elevate your CDI practices. Encourage your hospital or health system to sign up today! The path to financial success lies in effective and resilient revenue optimization.  How can you achieve revenue optimization? By accurately capturing the patient's story through concise documentation and precise coding. The key is to enhance revenue with integrity while reducing denials through authentic storytelling. A proactive approach is essential to mitigating risks associated with malpractice and payment denials. ℹ️ Ready to Learn More? For more information about our CDI MasterClass program and to receive a copy of the curriculum principles, email us at [email protected]. Take the first step towards a successful and cohesive CDI strategy! Join us today and make a lasting impact on your healthcare team’s performance! AHIMA American College of Physician Advisors (ACPA) American Medical Association American Hospital Association Healthcare Financial Management Association (HFMA) Health Care Compliance Association (HCCA) American College of Healthcare Executives

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

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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.

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Hmmm...$2B is a lot of cost cutting. Eliminating 2500 corporate jobs may be the tip of the iceberg. From my perspective, Aetna's significant challenges are contract rates outside the old US Healthcare markets, customer mix, technology and infrastructure. Is separating the insurance business a first step toward selling it? Would they keep the NE Corridor? Who would be a likely buyer? How would you split up the business for sale to avoid years of anti-trust challenges?is this really an exit MA play? Will getting out of MA really solve their problems? Cigna is doing it. Is that the model? Is a stand alone pharmacy business and probably the reinsurance arm a better bet than making the investment in true integration? Many questions ... Will be interesting to watch.

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The recent article by The Washington Post sheds light on a critical issue plaguing our #healthcare system: the impact of profit-driven consolidation by private equity firms. A new study by physician researchers reveals a troubling trend—when #privateequity firms acquire hospitals, they often liquidate assets instead of investing in patient care. But you shouldn't be shocked. “While private equity investors claim they infuse much-needed capital into the hospitals they buy, we found just the opposite: private equity firms quickly liquidate hospitals’ assets,” said lead author Elizabeth Schrier, a resident physician at the University of California at San Francisco. We have to remember, the primary goal of private equity ownership is always to make a #profit. To achieve this, firms focus on increasing revenues and decreasing expenses. Unfortunately, reducing expenses often involves shedding services and assets with lower returns on investment. These are frequently the very services that address essential patient needs. This practice underscores a fundamental flaw in our healthcare system—financial incentives drive decisions rather than patient care. As private equity firms continue to consolidate healthcare facilities, it is imperative to scrutinize their impact on patient care. Policymakers, healthcare leaders, and the community must advocate for regulations and practices that ensure financial decisions do not undermine the quality and accessibility of healthcare services. #healthcareconsolidation #PE #hospitals #healthcare #patients #physicians ABIG Health UNC Kenan-Flagler Business School MBA@UNC ESCP Business Schoolf Meroka Radiant Healthcare https://lnkd.in/d8Vw3uVi

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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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We expect to see the final specifications on #CMMI #TEAM model in the next couple of weeks. Please check out this short but very substantive guide for hospitals on how to prepare.

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This is still true, even more so now, after a global pandemic. #Navigators in both the federally facilitated marketplace states and states with their own marketplace are a stabilizing workforce for their community when it comes to understanding when to enroll in coverage, how to choose a plan, what the plan changes are each year, how out of pocket costs vary, which networks to choose, when to appeal decisions, what preventive benefits are, how to read billing statements, translate in multiple languages, unpack complicated insurance jargon, and more. Please share! #Outreach #Enrollment #Medicaid #ACA #Healthcare

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Cultivating a Collaborative Healthcare Culture: Team Building and Leadership in Action Success in healthcare hinges on a foundation of team building, leadership, mutual respect, collaboration, and cooperation. This isn't just our approach at the forefront of patient care; it's our unwavering work attitude at the heart of every medical endeavor. Our guiding principle is mutual respect, recognizing the unique strengths each team member brings to the healthcare mosaic. This respect creates an environment where innovative ideas flourish, creating a space where everyone feels valued and heard. Leadership is a shared responsibility, from medical professionals to support staff, each member contributes to steering the ship toward our shared objective – providing exceptional healthcare. This leadership model ensures that everyone plays a vital role in the success of the institution. Collaboration and cooperation are embedded in our ethos. Our interdisciplinary collaboration ensures a holistic approach to patient well-being. By working seamlessly across departments, we create an environment where the sum is greater than its parts. We actively engage in initiatives to share our knowledge, resources, and best practices with fellow healthcare professionals and institutions, aiming to elevate the standard of healthcare globally. Our focus goes beyond personal success. We invest in the growth and development of each team member, fostering a workforce that is not only skilled but also passionately dedicated to our mission. By helping our team members succeed, we enhance the quality of care we provide to our patients. At the heart of our healthcare philosophy is a commitment to team building, leadership, mutual respect, collaboration, and cooperation. By sharing our approach, we aspire to inspire others in the healthcare community to join hands, fostering a culture where collective achievements lead to a healthier and more compassionate world. #HealthcareCulture #TeamBuildingInHealthcare #LeadershipInMedicine #CollaborativeHealthcare #GlobalHealth #TeamworkInHealthcare

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In my new piece, I will dissect this issue from various angles regarding the for-profit healthcare model and the debate, prompting stakeholders, from doctors to economists, patients to lawmakers, to voice their concerns and opinions. The notion of for-profit healthcare is like a surgeon's scalpel—capable of healing, but also, in the wrong hands, capable of inflicting severe harm. #valuebasedcare #innovation

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Incorporating value-based contract strategies is not just about adapting to changes in healthcare reimbursement — it’s about taking a proactive approach to delivering care that truly benefits patients. As managed care organizations continue seeking providers who can offer high-quality, cost-effective care, those who master the art of value-based contracting will find themselves at the forefront of the industry. Now is the time to embrace these strategies, innovate your care delivery, and maximize the value you bring to your patients and partners.

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“The Future of Value-Based Care and Outpatient Joint Replacement” By: Nate Holton, MHA, PHD. Value-Based Care (VBC) represents a transformative shift in healthcare from quantity to quality. Rather than compensating providers per procedure, VBC rewards them for achieving better patient outcomes and delivering high value. This approach is particularly relevant in orthopedic joint replacement, where the success of surgery and recovery directly impact healthcare value. In the coming years, VBC will likely align more closely with outpatient surgery centers for joint replacements. These centers offer a cost-effective environment where quality standards can still be met. With fewer overhead expenses than hospitals, outpatient centers reduce overall costs for joint replacement surgeries, which aligns with VBC’s emphasis on efficiency and high-quality care. Advances in surgical techniques and pain management now make it possible for patients to recover safely at home, making outpatient centers a viable alternative to traditional inpatient care. To support this shift, orthopedic device companies will need to innovate with solutions that meet the needs of outpatient settings. However, it’s not just about speed or quick recovery—innovation must focus on accurate, cost-effective technologies that provide the best outcomes without losing sight of reimbursement structures and bundled care processes. This means delivering precise information and products that enhance the entire care pathway, ensuring every step contributes meaningfully to patient health and cost sustainability. Sources: Health Affairs, CMS.gov, American Association of Hip and Knee Surgeons. Journal of Orthopaedic Research New England Journal of Medicine What are your thoughts, LinkedIn? Do you agree or disagree with these anticipated changes? #healthcare #devicenation #meddevvice #medicaldevice #orthosales #valuebasedcare #vbc #outpatientjointd

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📣 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

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ASCs see post-procedure payer clawbacks intensify It seems like the payers now have a new trick up their sleeves to continue earning record profits at the expense of the providers. As if the payer's unrelenting efforts to reduce their medical loss ratio and thereby increase profits by engaging "cost containment companies" like Cotiviti, Gainwell Technologies, Optum, Varis, CGI Proper Pay, Performat, etc. These vulture companies are out there earning their commissions, often issuing egregious clinical validation denials and now trying to recover monies paid to providers that were previously authorized by the payer. In my mind, that is unconscionable and borders on unethical behavior. Speaking of clinical validation denials, it amazes me that these CDI and coding individuals working for these auditors are allowed to maintain their credentials. The credentials are intended to represent skill sets and core competencies in coding and clinical documentation improvement, a commitment to maintaining relevance and proficiency in their respective profession. These individuals chose to use their skill sets against providers, where most of these individuals began their careers #trickupthesleeves, #denypaymentafterthefact, #denypaymentafteauthorizing, #egregious, #doianythingforprofts, #overzealousreviwers https://lnkd.in/eRiakXN5

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I recently had the privilege of conversing with Joe Kiani, a trailblazer in the healthcare industry and a visionary leader. Our discussion centered around his innovative approach to making healthcare more accessible and efficient for everyone. Joe Kiani emphasized the importance of leveraging technology to provide high-quality care  -- including in the comfort of patients' homes. This not only improves patient outcomes but also reduces the burden on our healthcare system. His work is a testament to how technological advancements can bridge gaps in care delivery and bring about transformative change. One key takeaway from our conversation was Joe's commitment to patient-centered care. By focusing on continuous monitoring and early intervention, we can significantly enhance patient experiences and outcomes. His vision aligns perfectly with the growing trend of personalized medicine and the need for more flexible healthcare solutions – including when it comes to addiction. I love talking to leaders – especially in healthcare – and learning more about their style. Take a listen to how he talks about microfixing and his need to tackle big problems, while at the same time, speaking up when he sees injustice. Let's keep pushing the boundaries and working towards a more inclusive and efficient healthcare system! #HealthcareInnovation #HomeBasedCare #PatientCenteredCare #TechInHealthcare #HealthcareLeaders #Inspiration

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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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New Medpac report raises questions about prior auth But… “In 2021, MA plans made about 37.5 million prior authorization determinations, or about 1.5 determinations per enrollee. Overall, we found that 95 percent of prior authorization requests had fully favorable decisions.” “Providers or beneficiaries requested that MA plans redetermine 11 percent of negative prior authorization decisions in 2021. Eighty percent of those requests had fully favorable decisions. For those requests that had an unfavorable decision, an independent review entity upheld the MA plan’s decision most of the time” BUT..the report doubles down to say: “Office of Inspector General audits suggest that many denied requests should have been approved.” “We selected a stratified random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest MAOs during June 1-7, 2019.” Hmm off the cuff it seems like of the almost 1.9 M that’s not statistically significant. What the data show: The providers seem to be reluctant to appeal many of the denials as only a little more than 1 in 10 of the denials are appealed. And 1.6M are not approved or appealed. Besides the underpowered OIG report, the report quotes the burden on the doctors and is fairly consistent with a consensus-based Commission with 4 hospital Commissioners. As always I want to know more for instance Part B drugs are the largest segment - what part b drugs had prior auths and why. (See in comments for the answer.) #MA #Oncology #priorauth

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For me it’s pretty simple. The practice of medicine is hard. The practice of medicine has become even more difficult with third party interference and rationing of physicians clinical practice (insurers, PBMs, hospital admins, EHR companies and the Govemenment). That being said, Manufacturing and producing optimal Preventive, medical, surgical and palliative clinical outcomes at the lowest possible costs is hard work for physicians. What the failure of the Walmart primary care centers and other similar corporate ventures which have failed like Haven, CVS, etc simply means is it has become even more difficult in America to siphon healthcare funding from the bedside, where outcomes are manufactured by physicians with patients, back into Boardrooms in order to satisfy Walmarts shareholders, bond holders, executives, bureaucrats and their patron politicians. Walmarts failure won’t mean anything for the future of primary care which is doomed in America due to lack of funding alongside rhe rise of MedMal risk. Robert Bowman https://lnkd.in/e-XZWJj3 Sent from cell phone pardon the typos

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