Ann M. Richardson, MBA

Read the articles of the new issue of the #quality #patientsafety

1

For 11 consecutive years, reports like this one have found that the prices providers (hospitals, physicians, etc.) charge are the main factor driving Massachusetts’ high health care costs. While we value our hospitals and our health care institutions, it’s worth asking – what are we as taxpayers paying for, and at what cost? Individuals on Medicaid (taxpayer-funded) pay minimal to zero costs (~1/3 of the state’s population) and Medicare (taxpayer-funded) cost share is graduated based on income. But, for people with private health insurance (employer-sponsored health insurance, like Wellpoint members) health care premiums and out-of-pocket costs are taking up a significant –and growing– part of their income- between 20% to 40%. Perhaps it’s time to re-evaluate how taxpayer funds are being used to support health care and work with policymakers to reform reimbursements as means to help people stay healthy and out of hospitals.  In the meantime, below are some steps people can take to start understanding health care costs and stay healthy:   1. Think health, not sick care: eat healthy, exercise regularly, and stay active every day; 2. Take control of your health. Partner with your primary care team and be sure to get recommended preventive care and screenings; 3. Use primary care, urgent care, and community health centers for non-emergent care. These locations are the lower cost alternatives; 4. Understand how using hospitals and emergency rooms for primary care and routine services affects your premiums and out-of-pocket costs. #healthnotsickcare #health #wellbeing #finance #healthcare #value #employer #insurance #healthinsurance #affordability #transparency #incentiveswork https://lnkd.in/dV9SMPFU  

38

4 Comments

Who's going to buy Steward's remaining Massachusetts hospitals? Physicians can't own hospitals. Legislators have turned up the heat and regulatory scrutiny of PE and VC-backed healthcare (in large part because of Steward's bad apples). Smaller independent community hospitals (of which there are now few) are already struggling financially. Enter large, market dominant health systems? The state has made it clear it's not thrilled about Mass General Brigham owning more hospitals. (Instead, they've spun up outpatient centers in HNW areas and turned their attention to neighboring states). As a condition of approving its merger, Beth Israel Lahey Health agreed to a 7-year moratorium on cost increases among other concessions. That's set to expire in the next year or so. Do we really want more health system consolidation? (Studies would suggest the answer is "no" if you want lower prices, demonstrably better care and access, and fewer employed physicians). So, who's left? Are we willing to think a bit differently? Explore alternative options? Allow physicians or physician groups with business partners to make a go of it? (The horror, the horror). Can we admit that regulatory grandstanding has created as many, if not more, problems than it has solved? This is an opportunity to be a little bold. We shouldn't abide conflicts of interest or allow free reign for fraud and abuse. Oversight and transparency are paramount. But we can use a deft touch instead of a heavy hand. We can support innovation, not stifle it. This goes not just for Steward, but for efforts across the country to tackle hard problems by taking a different angle. Otherwise, get ready for more of the same. Same wolf, different clothing. #health #healthcare #medicine

54

19 Comments

Remote patient monitoring has so many benefits, including the reduction of avoidable readmissions! #valuebasedcare #remotepatientmonitoring #caremanagement #populationhealth

22

As a leader in healthcare, I believe it's crucial to speak up about quality concerns to ensure the best patient outcomes. We must create a safe space where everyone feels empowered to voice their concerns without fear of retaliation. Open communication and trust are the foundations of continuous improvement and patient safety. We must work together to foster an environment where every voice is heard and valued.

5

1 Comment

DAX Copilot automatically documents the patient/physician conversation, reducing physician burnout and increasing productivity. Learn more at https://lnkd.in/e86xfcb7

1

I’m a big fan of Hartford HealthCare. I’ve personally been treated there, had surgeries there and recommended their services to many friends and family members. In the last couple of years HHC has made incredible strides to achieve A level quality grades from Leapfrog and they’ve integrated lots of state of the art innovation. Unfortunately, because there is no functional marketplace for health services here in Connecticut; HHC continues to charge the prices that purchasers will pay. There hasn’t been anything to change that trajectory. Employer purchasers have sat on the side-line for decades. Ask an employer what they pay for specific health services and they are basically clueless. Things are changing here in Connecticut and nationwide. Employers are waking up to their fiduciary duty to act (contract for services) only in the best interests of their plan beneficiaries. They need to know what services cost, what they should cost and what they COULD cost or run the risk of being fined or sued by their plan members. Here, a union is suing HHC for price fixing and monopolization. In other states, employers themselves are being sued for breaching their duty to plan members. Employers, because of CAA are FINALLY securing their data on their populations and actually seeing what they’re paying and once they see it, in many cases, are horrified at the prices they’re paying. In other states, competing health systems are tactically establishing direct to employer functionality to take advantage of this new opportunity; they’re going at risk with employers on their populations. Effectively, they’re furnishing a marketplace solution designed to align their supply of services with the SPECIFIC population based needs of the employer. Perhaps, the largest employer in the state of CT, aka The State of CT Employee Health Plan, will assert itself to demand accountability for health services costs. That would certainly send a signal to all health systems that accountability is now a real thing. My guess is that health systems will react when and if the largest purchasers demand that they do so. This is a story that is and will continue to play out nationally. #hospital #healthcosts #monopoly #healthcare #healthleadership #paymentreform #caretransformation #CAA #fiduciaryduty #healthmarketplace Christine Arnold John Rodis, MD Lisa Trumble Moving to Value Alliance Chris Deacon Peter Hayes Patrick Long Al Lewis 🇺🇦 Brian Klepper Cora Opsahl Stacey Richter Julie Selesnick Jamie Greenleaf AIF, CBFA, C(k)P Justin Leader Stuart Sutley Michael Brouthers Derek Moore A. J. Loiacono Doug Aldeen Scott Haas Darren Fogarty Elizabeth Mitchell Dave Chase, Health Rosetta-discovering archaeologist 🎙Spencer Smith, CSFS® Raju Kattumenu Tim Denman Les Wilkinson Christopher Gormley Dean Jargo Wyatt Bosworth Kerry Wood Steve Schutzer, MD

62

17 Comments

Jeff Hogan does a great job explaining how hospital and health care spending can start to decrease, or at least not increase at double the rate of inflation, as it has for 20 years! As long as there is someone willing to pay the price, prices will rise. Employers (and their employees) must begin to leverage their purchasing power in the marketplace. We must all understand that Cigna, Aetna, United, Kaiser and Blue Cross/Anthem (now Elevance) are not “payers”. Employees, employers and taxpayers are the true payers through premiums, copays, deductibles, coinsurance and State (for Medicaid) and Federal (for Medicare) taxes.

17

5 Comments

2024 CDI Week Some suggestions for those CDI professionals celebrating CDI week this year: 1- Begin the process of transforming and updating CDI's role as a collaborator and facilitator of better physician documentation, recognizing that the physician is the only individual who can improve his/her documentation. A reasonable starting point is asking physicians how you can help them master documentation and charting in the EHR. Inquire as to what physicians desire and expect in a helpful CDI program, making the physician the focus of our attention. In short, how can we help physicians work smarter not harder with more time doctoring in front of the patient versus doctoring in front of the computer screen 2- Prepare for CDI week by beginning to become more proficient and knowledgeable in best practice standards of documentation. An ideal starting point is becoming familiar with the 2023 E & M documentation requirements, and being able to apply these standards in your chart review process. The History of Present Illness and Medical Decision Making within the H & P is vital in driving the establishment of medical necessity, an area that is often overlooked by CDI. Yes, CDI plays a role through more effective documentation in guiding physicians to support their clinical judgment that the patient needs to be hospitalized in an inpatient level of care 3- Commit to working onsite, hand in hand with Case Management, Utilization Review, and Physician Advisors. Working remotely five days per week creates too many roadblocks to collaborating with physicians and others using a multidisciplinary approach to documentation excellence. Like a used car salesman, out of sight out of mind. I have found that onsite CDI activities allow for more interaction with physicians and the multidisciplinary team. Remote CDI does not allow for critical situational awareness including providing feedback through conversation with physicians on documentation tips to consider in the future to better capture the patient's clinical story and support of clinical judgment and medical decision-making. Real-time feedback and documentation education are not effective through email. Physicians are bombarded with emails, they want fewer emails and more education on documentation #CDIweek, #happyCDIweek, #CDIhelpingphysicians, Cesar M. Limjoco, M.D. https://acdis.org/cdi-week

17

1 Comment

🚨 Top 10 #PatientSafety Concerns for 2024. 📌 Have significant changes been made over the last decade? An important question is to reflect on what has been done, what we are doing, and what remains to be done.

6

5 Comments

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

5

The recent updates to Appendix PP of the State Operations Manual in CMS's 902-page QSO memo signal key shifts in regulatory focus for Skilled Nursing Facilities (SNFs). Here’s a breakdown of the critical changes and their implications: Key Areas of Emphasis: 1. Antipsychotics and Schizophrenia Diagnoses: - CMS continues to target improper use of antipsychotics and inaccurate schizophrenia diagnoses. - Increased scrutiny of off-label medication use, especially those with sedating effects. 2. Resident Discharges: - Enhanced focus on ensuring discharge processes align with regulatory requirements and prioritize resident rights. 3. Medical Director Responsibilities: - Expanded expectations for medical directors to actively oversee care quality and regulatory compliance. 4. Quality Assurance and Performance Improvement (QAPI): - Greater emphasis on QAPI programs as tools for driving systemic quality improvements. - Facilities must demonstrate active and effective use of QAPI principles. 5. Pain Management: - Surveyors will examine policies and practices to ensure adequate pain management that aligns with residents’ needs and preferences. 6. COVID-19 Vaccination Education and Offerings: - Clear mandates on facilities to educate residents and staff on COVID-19 vaccination and to offer vaccines proactively. 7. Enhanced Barrier Precautions: - Reinforcement of previously issued guidance for infection prevention, now embedded into the manual. Changes to Critical Element Pathways: - Adjustments to survey probes to incorporate new guidance, ensuring surveyor focus aligns with updated regulatory requirements. Implementation Timeline: - Effective Date: February 24, 2025. - Immediate Implications: Although formal implementation is months away, surveyors are likely to prioritize these areas during inspections immediately, reflecting their longstanding focus. Training and Preparation: - CMS plans to provide public training for surveyors on these updates. Providers should stay informed and use the training materials to align their operations with the revised expectations. Action Steps for SNFs: Review and Update Policies: Evaluate policies on medication management, discharge planning, QAPI, and infection prevention. Education and Training: Train staff on pain management, COVID-19 vaccine protocols, and enhanced barrier precautions. Medical Director Engagement: Ensure active involvement of medical directors in quality oversight. Audit Practices: Conduct internal audits to identify and address potential non-compliance in the highlighted areas. This updated guidance underscores CMS's ongoing commitment to resident safety and quality care, signaling a proactive stance that SNFs must adopt to remain compliant and survey-ready. https://lnkd.in/gcqzMyHk

23

New Episode #354 of the CodeCast Podcast. Join us as Terry covers questions covering risk support for E/M, Telehealth in the hospital setting, missed appointments, follow-up testing protocols, shared visit modifiers, and more. Tune in here:https://lnkd.in/gnW3-heX #TerryTuesday #CodeCast #Top10Tuesday #podcast

38

3 Comments

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

2

This CE learning activity is open to nonmembers. This program will help you navigate the latest #supplydisruption. FYI, members have access to this type of cutting-edge programming all the time. #webinar #healthcaresupplychain #FOMO #lab #nursing

2

As highlighted in this McKnight's article, "Vigilance, solid systems, needed ahead of extensive survey changes, nursing home experts warn," staying ahead of the game is critical for success! Upcoming survey changes mean proactive quality management systems are more important than ever. Nursing homes must focus on: ✅ Building robust systematic processes ✅ Continuously monitoring care standards ✅ Building a culture of continuous improvement 🔑 Why it matters: Quality management isn't just about passing surveys—it's about delivering the best care to residents while avoiding costly pitfalls. The key? Stay vigilant, stay prepared, and make quality improvement a daily habit. Let’s ensure our systems are ready for these changes! #quality #performanceexcellence

7

1 Comment

I know it is self-serving, but this is a really stellar panel. I'm looking forward to a really thoughtful conversation about one of the most complex issues in health care: How can we get away from distorted markets and broken pricing models which favor opacity and lack of information in favor of one where the purchasers are actually able to buy high quality products and services at competitive prices. This panel alone is worth the price of admission! (And we've got many other stellar panels at the conference.)

49

1 Comment

Off-Cycle SNF Provider Revalidation: Mandatory Form CMS-855A Top 7 Things To Know: 1. Mandatory Revalidation: Starting October 1, 2024, all SNFs must revalidate their Medicare enrollment by the end of the year. This process requires completing an updated CMS provider enrollment form, which now asks for more detailed information than before. 2. Off-Cycle Revalidation: Normally, provider revalidation happens on a regular cycle. However, this "off-cycle" revalidation is a one-time requirement starting this year, impacting 100% of SNFs, regardless of their size or ownership structure. 3. CMS Enrollment Form 855A: The new form, which must be completed by SNFs, is longer (20 pages compared to the previous 14 pages) and includes additional sections about "Additional Disclosable Parties" (ADP). SNFs must provide detailed information about all ADPs that have a significant operational or financial role in the facility. Providers can access the form via the PECOS (Provider Enrollment, Chain, and Ownership System) online platform. ·     Visit the PECOS website: https://lnkd.in/g5kBTqfW ·     Log in using your CMS credentials. ·     Locate the revalidation section. ·     Link to CMS 855A Form: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://lnkd.in/gqAvEnZk 4.    Timeline: ·     CMS will send letters to SNFs starting on October 1, 2024, and through the end of the year. ·     Providers have 90 days to respond after receiving the letter. ·     Failure to complete the revalidation in time could disrupt the facility's ability to bill Medicare.   5.    Additional Disclosable Parties (ADP): This is a key new requirement. An ADP is anyone or any entity that: ·     Has significant operational, financial, or managerial control over the SNF. ·     Owns, leases, or subleases property to the SNF. ·     Provides management, consulting, or financial services to the SNF. This information must be disclosed in the new enrollment form. 6. Importance of Compliance: SNFs must complete this revalidation within the specified timeframe to avoid disruptions in their Medicare billing. Providers are advised to consult legal counsel to ensure they correctly interpret the reporting requirements and avoid errors in their submissions. 7. PECOS System: The information must be submitted through the PECOS system, which is the online system used by CMS for provider enrollment. This process requires more detailed reporting, especially concerning the ownership and operational control of SNFs and the ADPs involved with the facility. Since all SNFs are affected, every provider should be prepared for this and take timely action to prevent any interruption in Medicare billing. Failure to comply could result in significant financial issues for the facility. #SNFCompliance #MedicareRevalidation #CMSUpdates #HealthcareProviders #HealthcareCompliance #CMSFrom855A

20

3 Comments