Ryan T. Mackman, MBA, MHA, CLSSGB

Dr Jaime Bland DNP, RN-BC leading a great session at the Iowa Healthcare Collaborative Annual Event on Clinical and Claims Data. Some key takeaways: - one person one record: critical for coordination of care - data sharing improves quality measurement and patient safety - an enterprise master person index is critical to matching the right records for the right individual and making that information available to clinicians and care providers

25

9 Strategies for Diagnosing and Treating Cash Flow Problems Check out the latest Practice Management Institute / The Michigan Society of Hematology and Oncology article in the July issue of Oncology Practice Management magazine! The article, written by industry expert and PMI faculty member Jamie Claypool CMPE,CPC,CPMA, CMCA-EM, is worth the read!   “In the 30 years of my physician practice consulting career, I have learned a number of ways to diagnose and treat cash-flow problems. Some problems were easy to diagnose and others a bit more difficult, with many “differential diagnoses” along the way. While providing practice assessments to my clients, I developed various strategies that I consider productive. People in revenue cycle management may find some of the techniques I am suggesting part of their everyday routines. However, if you are a practice owner, an office manager who is not a professional financial manager, or a veteran billing and practice management staff member, you may be helped by these strategies.” Read the full article here #PMIPARTNERSHIPS

8

2 Comments

🔎 Senators See Possible Conflicts of Interest in Health Care Pricing Tools The chairmen of two Senate committees overseeing health policy, Ron Wyden of Oregon and Bernie Sanders of Vermont, are looking into the practices of data analytics firm MultiPlan. Concerned about companies prioritizing their own profits over patient well-being, the senators are investigating MultiPlan's business model, which recommends lower payments to medical providers. This model could lead to a conflict of interest, as MultiPlan and insurers can collect higher fees when payouts are lower. The senators have called on MultiPlan to discuss their investigation and address concerns raised by a recent New York Times article. Read the full article here: Senators See Possible Conflicts of Interest in Health Care Pricing Tools MultiPlan has stated that they are working with the Senate committees to explain the complexities patients face when choosing high-priced care outside their networks, emphasizing their commitment to making healthcare transparent, fair, and affordable for all. This inquiry reflects the growing scrutiny of MultiPlan, which has faced allegations of anticompetitive behavior and collusion with insurers to fix prices. The Department of Labor also has ongoing investigations into the type of pricing services provided by MultiPlan. The attention on MultiPlan highlights the importance of employer-based health insurance, which is the most common way Americans receive coverage. Employers are increasingly looking into the cost of administering their plans and are frustrated by limited access to claims data. Legislation has been introduced to address this issue, requiring insurers to provide employers with claims data. As the investigation unfolds, it remains to be seen how MultiPlan and insurers will address concerns and ensure that patient well-being is prioritized over profits. #HealthCarePricing #PatientAdvocacy #HealthInsurance #DataAnalytics #SenateCommittees

2

For 2025, regulators approved the following average increases for health insurers in the individual market: Blue Cross HMO: 11.56% Health Partners: 9.71% Medica: 1.95% Quartz Health Plan: 9.43% UCare: 8.8% Costs of Medical care continue to increase. As a country we spend so much more on heath care compared to others - If we could spend less on health care more could be spent in other areas that has impact. Education and Social determinatives of heath ( Housing,food,transaportation), defense and economic growth. The cost of health care is having negative effect on our culture. Make it a conversation that says it needs to be addressed.

25

4 Comments

A brief thread on how MLR is often a stat that is juked (h/t to The Wire) in the “value-based” care world. The medical loss ratio (MLR) is a financial metric used in health insurance and managed health care to measure how much of a premium dollar an insurer uses to pay medical claims and quality improvement activities. The MLR is also known as the medical care ratio, medical cost ratio, or medical benefit ratio (cite: Healthcare.Gov). Many so-called value-based care models cite their impact in the form of medical loss ratio improvement. Most innocently assume that such improvement is generated by better medical management (I did when I first started working in the field). While this may be the case in some models—it is importantly to note that another way to improve a medical loss ratio is be increasing revenue capture in the form of coding. Said another way, to improve MLR, one can reduce the numerator or increase the denominator. Therefore, when someone cites a major medical loss ratio improvement—the key question to ask is: did the MLR improve because of true medical utilization reduction or because of better revenue capture? Most will glibly (and sometimes dishonestly) say “both.” At which point it’s important to ask, what fraction of Medical Loss Ratio improvement arose from better medical management and what fraction from better revenue capture. Usually, what we will find is that most dramatic improvements in MLR are a function of improvements in revenue capture—and only marginal improvements in medical cost-management. In that way, the so-called “value” produced by many value-based care models isn’t true value. It’s better revenue capture. And many “value-based” care models have been granted undue recognition for medical cost management—citing filthy MLR improvements—that are associated with minimal true improvement in medical expense. This kind of short-cut taking sets back the whole value-based care movement which (while appropriate revenue capture is necessary) should be about overall better cost management and reducing total cost of care—not better revenue capture alone.

528

66 Comments

Check out the attached report from the Midwest Business Group on Health covering Chronic Kidney Disease (CKD) and the associated impact to employers. As stated in the report, treating a single case of advanced CKD can exceed $90,000 per year for the employer. And since there's no cure, the costs continue to mount (dialysis, kidney transplant, etc.). However, early diagnosis can dramatically improve outcomes and reduce treatment costs - which means #preventivescreenings can mitigate risk. We can help. Our Creatinine w/eGFR test is one of the key methods of detecting CKD, as indicated in the Action Brief below. It's one of my top recommendations for every client, not only because of the efficacy - but because my grandfather lost his battle with CKD in his early 50's. Let's chat about how we can prevent CKD in your population today. #chronickidneydisease #biometricscreenings #populationhealth

13

The highest increase since 2012 highlights the pressing need for further action to curb increases in medical cost trend. Insurers should prepare for tougher contract negotiations as providers strive to enhance their financial standing and offset stagnant Medicare and Medicaid reimbursement rates.

33

3 Comments

As policymakers consider changes to the Medicare Advantage (MA) program, it's essential to acknowledge the diversity of D-SNP and MA-PD plans. A one-size-fits-all approach may fail to address the unique needs of these plans and lead to unintended consequences for Medicare beneficiaries. Thoughtful and tailored policy decisions can help ensure that all beneficiaries receive the care and support they desire and deserve. Our new Association for Community Affiliated Plans (ACAP) report shares specific policy recommendations and options for consideration: https://bit.ly/4dHIpWj #MedicareAdvantage #DSNP 

10

Here are five strategies for how healthcare providers can use claims, clinical data and benchmarking services to maximize their potential with payers.

3

Minnesota-based Mayo Clinic and St. Louis-based Mercy have formed a partnership in which the two organizations will de-identify patient data as they search for new ways to diagnose, treat and prevent disease. They'll do so through Mayo Clinic Platform_Connect, a distributed data network that provides secure access to de-identified clinical data. Previously, Mercy and Mayo Clinic could use Connect to analyze data from their own organizations, but as of this week, each organization can safely and securely analyze de-identified patient data from either health system. This significantly larger data set allows researchers and innovators to better identify risk factors, predict illnesses and provide earlier treatment, the organizations said. https://lnkd.in/ge2e-EZf

3

While the industry is experiencing a plethora of regulatory changes, mounting litigation, new and complex coding changes, it is vital that health plans and providers are armed with everything they need to survive. Hear your peers discuss real world solutions and practical options to optimize your comprehensive risk adjustment strategies. You won’t want to miss this event. You will gain best practices for strengthening your risk adjustment strategy plan. Hear how others in your position are navigating these risk adjustment complexities. Register today,

4

The discussion around real-world, synthetic, and de-identified data in #HealthcareAnalytics highlights an essential truth: the data you use doesn’t just inform insights—it shapes the decisions that impact patient care and access. Each data type has unique strengths: real-world data provides depth and variability, while synthetic data offers scalability and privacy protections. However, the true power lies in integrating these sources with reimbursement and knowledgebase data. By combining these latter two data types, we can ensure that the best diagnostics are not only developed and validated but also reimbursed—making them accessible to patients who need them most. Adding real-world data further enhances this process to demonstrate clinical utility when new biomarkers are tested, paving the way for reimbursement frameworks to support the rapid translation of innovation to the practice of medicine. In healthcare, better decisions start with better data, applied strategically to advance #PrecisionMedicine and improve #PatientOutcomes.

27

1 Comment

MA: The "STAR" of the show. Silly me, given my recent articles on benchmarking and bidding in Medicare Advantage (MA) as well as the recent stargate fiasco that is happening this year, I thought I’d write a brief article that explains the basics around the star ratings. Well, just like those other topics, the details are super complicated and confusing. 2024 Star Ratings represent services provided in 2022, but don’t impact payments until 2025 and the technical notes include words and phrases like “clustering,” “relative distribution” and “Tukey outer fence outlier deletion.” So instead of a superficial overview, I am making the mistake of taking a deep dive into Star Ratings. I apologize in advance for pulling you down this rabbit hole with me. Given the extent of the information, I’m choosing to start off by sharing it in bite sized pieces and will then post the whole thing in its entirety once I’m finished. Let's start off with...Why do we even have Star Ratings? As you know, in Medicare Advantage, private health plans are paid a fixed monthly amount for each of the Medicare beneficiaries that are signed up with their plan. Given the number of options an individual beneficiary may have to choose from, CMS wanted to help them choose the best plan for them and not just incentivize plans to provide high quality care, but to facilitate growth in the best performers. At a high level, the Star Rating system has two impacts: a guide to consumers choosing among MA plans and as a factor in determining MA plan payments. It is important to remember that there is no real quality data for Traditional Medicare, so star ratings only enable comparisons between MA plans and not between MA and Traditional FFS Medicare. #MA #Medicare #Stars #Tukey

27

2 Comments

🚨 2025 Medicare Physician Fee Schedule Update The recent Medicare Physician Fee Schedule proposal for 2025 could have a significant impact on healthcare providers and practices across the country. 🏥 Check out this insightful article with comments from MGMA to learn more about what these changes might mean for your practice and how to prepare. 💡 👉 https://lnkd.in/guC9-_h2

5

🚨 Healthcare Alert: Changes in Medicare Advantage Plans 🚨 A recent HFMA survey of 135 health system CFOs reveals that: - 16% plan to stop accepting one or more Medicare Advantage (MA) plans within two years. - 45% are considering this move. - 62% find collecting from MA plans significantly harder than two years ago. These insights highlight growing challenges in managing MA plans. It's crucial for healthcare professionals to stay informed and proactive. #HealthcareFinance #MedicareAdvantage #HealthSystemCFOs #HFMA #MA #actuary

8

1 Comment

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

22

9 Comments

All attention is on government programs #Medicaid & #Medicare. The big three continue to build out #health services capabilities to balance out the insurance risk. And all three own their own integrated #PBM’s

2