Rhonda Murray, MHA

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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🙌🏻 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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CMS Sunsets Medicare Advantage Value-Based Model: What It Means for Seniors and the Path Forward As we all been reading about. CMS recently announced the end of the Medicare Advantage Value-Based Insurance Design (VBID) model, citing significant costs and high risk scores. While financial concerns are driving this decision, it’s critical to recognize the benefits this model brought, particularly for low-income seniors and those managing chronic conditions. Why Higher Risk Scores Were Expected Higher risk scores were not a flaw but a feature of this model’s design given segmentation enrollment. By focusing on innovative, tailored solutions for vulnerable populations, the program naturally served those with more complex health needs. These scores reflect the success of the model in addressing care gaps and improving outcomes for seniors who need it most. Our Role At Alignment Health, participation in VBID was about designing products uniquely suited to the populations we serve. The flexibility allowed us to innovate and improve access to care for underserved communities. While we anticipated this transition and have plans in place to adapt, millions (approx 10 million plus) of seniors enrolled in VBID programs across the country may face challenges as this model sunsets. Acknowledging CMS and Looking Ahead While CMMI likely faced significant pressures from Capitol Hill and the Congressional Budget Office, we commend the VBID team and Liz for their exceptional work in fostering collaboration and advancing the mission of improving senior healthcare. The conclusion of this program highlights the need for ongoing innovation and advocacy to ensure seniors continue to receive high-quality, access and affordable care. Our Commitment to Seniors At Alignment, our mission remains unchanged: to deliver better care for seniors, particularly the most vulnerable among us. This decision strengthens our resolve to be a voice for those who need it most and to provide better choices and outcomes for the populations we serve. Change has always been an opportunity for innovation and creativity with product leading options. We are committed to working closely with CMS and other stakeholders to continue creating solutions that address disparities and improve healthcare for seniors across the nation. Together, we can build a stronger, more inclusive healthcare system for the future. #medicareadvantage #vbid #2026 #seniors #change #cmsannouncement

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Site-neutral payments refer to a Centers for Medicare & Medicaid Services policy in which the same medical services are reimbursed at the same rate, regardless of where they are provided. Currently, our healthcare system does not widely use this approach, with reimbursement rates varying based on the type of facility. However, there is increasing interest in expanding site-neutral payment reforms. I recently wrote a blog on this topic for The Alliance. Click below to learn how Medicare's site-neutral payments policy is emerging as a strategy to manage healthcare costs and what it could mean for self-funded employers. https://ow.ly/a82Y50T8Lpo

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Understanding your health plan's prices or your managed care contract is a very challenging task. The multitude of variables in claim pricing is astounding. Zip codes, provider credentialing, past visits, diagnosis codes, and obscure administrative guidelines, etc. create significant difficulty in determining the contract prices and ultimately the sufficiency of those prices for your health plan or managed care contract. Network and HealthPlans guard their pricing methods as intellectual property. It is critical to understand the impact of the pricing system for everyone involved to reduce this industry wide cost of healthcare payments A network or payer provides the output of their pricing mechanism through the traditional claim's payment process. Using the site specific, Medicare index for each code or DRG will allow a health plan or healthcare provider to determine what the sufficiency and payment adequacy for their claims and procedures. Even when the plan uses an alternative or proprietary pricing index, a Medicare index analysis gives you the information necessary to evaluate your health plan or contract prices. For certain, this Medicare index process is much easier to use and evaluate versus a machine-readable file! The cost of not understanding and using a Medicare index for all healthcare plans and provider contracts arises in the continual high (and higher!) cost of healthcare payments. Unnecessary claim appeals, phone calls, legal expenses and credit balances underscore the need to reconcile the prices for healthcare at your employer plan, medical provider, and insurance company. Imagine the wasted costs involved in trying to resolve healthcare payments between health plans, providers, employers and various ERISA plans. Is it about time we change the cost of healthcare payments?

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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 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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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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And there we have it! Tonight, many of us with pour over the 2025 Proposed Rule for the PFS. For 15+ straight years, the proposed rule includes a cut to the conversion factor, and we are possibly looking at a 6th straight year that some, or all, of that cut makes it into the Final Rule. For 15+ years, we have all written letters and signed petitions to end up in the same place with no real change in the slanted budget neutrality rule and actual recognition of the Medicare Economic Index. With 92% of healthcare providers continuing to see heavy increases in operating costs (MGMA), this isn't an equation that works, and it is going to break. Real change comes when the real problems are confronted, and we are a decade beyond having that conversation. #medicare #healthcarefinance

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The April final rule on #supplementalbenefits in #MedicareAdvantage is a big deal requiring immediate action from #healthplans. The Centers for Medicare & Medicaid Services (#CMS) regulations have 3 major components: evidence, eligibility and member awareness. Beginning with the CY2025 bid process, CMS will deny a plan’s bid if it hasn’t demonstrated that its proposed supplemental benefits for the #chronicallyill (#SSBCI) is reasonably expected to improve or maintain the health or overall function of its chronically ill enrollees. CMS is also implementing annual review of SSBCI offerings for compliance. To comply with the final rule, plans must do the following: ▶️ Establish an evidence-based bibliography of clinical literature for each SSBCI offering, showing it can reasonably improve or maintain the health of chronically ill enrollees. All supporting evidence must be published within 10 years of the coverage year. ▶️ Use written, objective criteria to determine an enrollee’s eligibility for SSBCI, ensuring they meet the definition of “chronically ill enrollee” with complex conditions needing intensive care coordination. MAOs must also document when enrollees are deemed ineligible to ensure equitable access to benefits. ▶️ Include an all-channel disclaimer listing the chronic conditions required for eligibility and clarifying that additional criteria may apply. ▶️ Beginning January 1, 2026, MAOs must send mid-year notifications annually each July to each enrollee with unused supplemental benefits. CMS requires the mid-year notice to support #healthequity and inform enrollees about unused supplemental benefits. These new requirements impose huge new operational challenges for plans under tight deadlines. Get cracking now. Full rule: https://lnkd.in/e8GwBmCq

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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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The Basics of Risk Adjustment Here’s what stood out to me: In capitated payment models, accurately predicting patients’ future healthcare costs is critical. Risk adjustment helps ensure that providers are paid enough to deliver appropriate care to all their patients, regardless of their individual care needs. However, if done poorly, it could exacerbate health inequities by misallocating resources. Check out the full piece below: https://buff.ly/3yPjVfn #healthcare #hospitals #doctors #riskadjustment #individualcare

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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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Updated Questions Questions Questions: Lequembi and CMS (with two answers) Here is what CMS said to STAT: "Medicare’s actuaries expect the drug Leqembi, made by the Japanese drugmaker Eisai and sold in partnership with Biogen, to cost the traditional Medicare program around $550 million in 2024, and the entire Medicare program $3.5 billion in 2025, a spokesperson for the Centers for Medicare and Medicaid Services confirmed to STAT. That projection forecasts a large increase in uptake over the next year and a half." As usual I just have questions: 1) Is this the actuarial contingency margin or actual expected expenditures? Answer expected expenditures (OACT) 2) Does that estimate include the cost of diagnosis and checking that patients do not have ARIA? Answer The PMPM estimates include the cost of the drugs themselves, the cost for administration of the drug, and the costs of associated diagnostic testing and office visits. (OACT) 3) If just the drug, did the actuaries consider the primary site of service is the HOPD where drugs are part of the overall budget neutrality equation? Its not like physician fee schedule where drugs were separated from the other fees. 4) Are rural hospital proponents examining Medicare hospital outpatient payments shift away from smaller urban and rural facilities to large urban due to the addition of these and similar highly complex services. (I note the cost of the "340B" fix demonstrated the link clearly for all to see in the HOPD final rule for 2023* I'll put the shift at the bottom.)) Example of budget neutrality shift: "As required by statute, CMS implemented a 3.09% reduction to the payment rates for non-drug items and services to achieve budget neutrality for the 340B drug payment rate change for CY 2023." #lequembi #CMSOACT #ruralhospitals

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How does a $497k chart audit risk turn into a recommended $6.8M recoupment? Impact extrapolation, that is how. The rule now allowing the OIG to recommend larger recoupments are now in effect. This is the first of two audits published today. It isn't too often that the OIG publishes not one, but two, findings reports in a day. Let's dig into the first one. The article linked below is tied to a 2017 and 2018 date of service audit of high risk diagnosis codes by the OIG. Beginning with 2018 dates of service the OIG is able to recommend that dollar impacts reflect the extrapolated error rates from their reviews. This is highly controversial because of financial magnitude and the approach to extrapolation. This marks one of the first ones that I have seen. In this audit the OIG reviewed 240 conditions from the years in question. There are 8 conditions that were reviewed during the audit. They were stroke, heart attack, embolism, sepsis, lung cancer, breast cancer, colon cancer, and prostate cancer. What jumps out to me in this review is the sepsis category. This is the first time I have seen sepsis as a high risk diagnosis. In fact, sepsis and pressure ulcers are in the other review (which I will post shortly). The story continues to be the same. Acute conditions being captured when they often represent historical conditions. In fact for the cancers, strokes, and heart attacks a whopping 93.3% (168 of 180) were found to not be valid. This is in line with prior reviews. Organizations, both payers and providers, must have processes in place to identify and review these. For the sepsis patients, 30% were rejected. While higher than desired, this is significantly lower than other targeted conditions the OIG historically reviews. The call to action for organizations is simple: 1) Know your data- know what patients you have, what conditions they have, and what you are billing for your patients. 2) Increase scrutiny on high risk conditions- if a patient has a stroke, heart attack, or cancer that is captured by a PCP or captured only once in a calendar year it is worth a second review. 3) Educate providers- it is critical to educate providers on the difference between active conditions and historical conditions. There is often no ill intent by providers rather it is matter of coding appropriateness. Leverage your experts to help them know the rules. Enjoy your Wednesday! https://lnkd.in/eX7tjgyB

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What does health insurance do? The conversation in the attached screenshot sums it up. We have a distorted market in healthcare. For drugs, there is a middleman called PBM between the insurance and the drug companies. The PBM negotiates a higher rate than the cash price - usually 2x or 3x and then receives an under the table rebate from the drug company. It passes of portion of this rebate to the insurer. The end effect is that the bottom price for the consumer is increased. The consumer believes that their insurance saved them a lot of money. #healthcare

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𝗪𝗵𝗮𝘁 𝗰𝗼𝘂𝗹𝗱 𝘄𝗲 𝗴𝗲𝘁 𝗳𝗿𝗼𝗺 𝗮 𝗧𝗿𝘂𝗺𝗽 𝗽𝗿𝗲𝘀𝗶𝗱𝗲𝗻𝗰𝘆 𝗿𝗲𝗹𝗮𝘁𝗲𝗱 𝘁𝗼 𝗵𝗲𝗮𝗹𝘁𝗵𝗰𝗮𝗿𝗲 𝗽𝗼𝗹𝗶𝗰𝘆 𝗮𝗻𝗱 𝗔𝗜: I align with almost nothing from DJT, but here’s where regulatory disruption could benefit healthcare. 👨‍⚕️🧑‍⚕️🩺 𝐏𝐡𝐲𝐬𝐢𝐜𝐢𝐚𝐧 𝐁𝐮𝐫𝐧𝐨𝐮𝐭 / 𝐋𝐞𝐚𝐯𝐢𝐧𝐠 𝐭𝐡𝐞 𝐁𝐞𝐝𝐬𝐢𝐝𝐞 — Streamline insurance documentation to essential data only — Adjust the 1997 residency cap for population and patient complexity — Loan forgiveness and financial incentives for high-burnout specialties — Increase pay for cognitive and primary care specialties — Reform malpractice laws to reduce defensive medicine — Streamline or outright kill prior authorization for 95% of claims — Nationalize medical licensure & simplify credentialing — Revise Stark Law — Set standards for NPPs / address scope creep 👵👴 𝐎𝐮𝐫 𝐀𝐠𝐢𝐧𝐠, 𝐂𝐡𝐫𝐨𝐧𝐢𝐜𝐚𝐥𝐥𝐲-𝐈𝐥𝐥 𝐏𝐨𝐩𝐮𝐥𝐚𝐭𝐢𝐨𝐧 — Reform Medicare to cover more home- and community-based services — Increase Medicaid funding for in-home care and HCBS — Develop a national long-term care insurance program — Expand Medicare hospice benefits and support end of life discussions — Provide tax credits, paid leave, and respite programs for family caregivers — Encourage longer-term prevention in medical care — Encourage longer-term prevention in society (food supply, exercise, substance use, mental health) 📝 𝐎𝐮𝐭𝐝𝐚𝐭𝐞𝐝 𝐑𝐞𝐠𝐮𝐥𝐚𝐭𝐢𝐨𝐧𝐬 —Modernize Medicare/Medicaid to focus on outcome-based measures — Simplify billing/reporting requirements to cut redundant paperwork — Develop safe harbors for evidence-based practices to reduce liability — Allow alternative care pathways in EMTALA to reduce ER congestion — Modernize HIPAA to promote privacy but also kill the fax machine  — Reform SNF and hospital care transitions, where massive gaps cause massive problems — Align incentives between individual physicians and health systems 🤖🔮 𝐅𝐨𝐫𝐰𝐚𝐫𝐝-𝐓𝐡𝐢𝐧𝐤𝐢𝐧𝐠 𝐀𝐈 𝐎𝐩𝐩𝐨𝐫𝐭𝐮𝐧𝐢𝐭𝐢𝐞𝐬 — Automate repetitive tasks like billing and data entry to ease administrative loads — Encourage creation and adoption of ML models for risk assessment in emergency care — Leverage AI for predictive population health and personalized patient care, with guardrails — Strengthen cybersecurity for AI tools handling patient data — Reforms that allow tested, trusted GenAI models to respond to patients with legal protections — Create a regulatory framework for AI adoption that is transparent and respects clinical judgment Healthcare does need disruption, but it's very easy to do it wrong.

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