James Hughes’ Post

My Thesis at the Society of Actuaries I’m speaking at the #SOA meeting next week, in a presentation that covers a range of topics with Tony Pistilli from Axene Health Partners, LLC and Brooks Conway of Oliver Wyman. My intentionally provocative thesis? #340B has become so big, so sprawling, so invasive—affecting, altering, morphing, distorting virtually every nook and cranny of #healthcare—that virtually any #health care related #actuarial analysis must focus on it and its impacts, or risk missing the boat. See you there! #lifesciences #managedcare #drugpricing #futurist #protect340B #pharmacies #hospitals #insurance #physicians #antitrust #healthcarecompetition #actuary

1,400 That’s the total headcount at last week's ParetoHealth Legend Re Members’ Meeting in Tampa, Florida! With 2+ days of education, networking and fun, our members, prospects, and consultant partners got to hear from industry experts on subjects like: 🔵 GLP-1’s & What to Do About Them 🔴 The Latest on Gene Therapies ⚫ Creating a Fiduciary Action Plan ⚪ The Growth of ParetoHealth 🔵 Our Healthy Balance Sheet 🔴 Innovations in Cost Management ⚫ Streamlining Renewals ⚪ And so much more! We have gotten feedback that this was our best event yet, and a few even said specifically this was the single best health insurance conference they have ever attended. Employers are desperate for a transition off the fully-insured hamster wheel that leaves them with few options, and even less data, to counteract their ever-increasing healthcare costs. ParetoHealth is an incredible alternative to that failing model, and our program offers employers both the long-term protection against large claims volatility and powerful claims management tools typically reserved for Fortune 500 companies. As our CEO Andrew Cavenagh said so well in his opening remarks, ParetoHealth is “where employers and consultants come to do self-insurance right, do it easily, and do it at scale”. Let’s do self-insurance right, easily, and at scale...TOGETHER. -Spence P.S. oh and that guy pictured on stage in front of a room of about 600 folks was yours truly leading a breakout session on Advanced Self-Funded Strategies 😎 #captives #healthcare #inflation #captiveinsurance #selffunding #selffunded #healthinsurance #newmodel #paradigmshift

The integration of an Insurance & TPA Feature in pathology lab software is paramount for efficient financial transactions and seamless healthcare delivery. Statistics reveal a notable 25% reduction in claim processing time, enhancing overall billing efficiency. Check Full Guide: https://lnkd.in/dujRswBT #pathology #pathologylab #pathologylabsoftware #labsoftware #pathologysoftware #LIMS #cloudbasedsoftware #CloudLIMS #labmanagement #laboratory #doctors #doctor #drlogy #drlogyplus #laboratory #lab #diagnostics #diagnostic #diagnosticservices #diagnosticsoftware #technology #patientdataanalysis #patientdata #TPA #Insurance

Managed Care History: From Kaiser to Skynet Medical Managed care in the United States has gone through three distinct phases in that time- from physician- and hospital-led HMOs to PPOs and “shadow” capitation via virtual networks like ACOs to machine-governed payment systems, where intelligent agents (AI) using machine learning are managing the flow of healthcare dollars on behalf of vast health financing conglomerates.  Power has steadily shifted in fifty years from those who provide care to those who pay for it. This is the first installment of a three part series on managed care history. Please read:  https://lnkd.in/ethqBgaD #HMO #KaiserPermanente #Capitation

Across many customer journeys in Insurance and healthcare, we constantly come up against information retrieval challenges. It could be a simple claim submission process (FNOL) involving emails from agents , extracting medical information from patient notes or a more complex use case like extracting information from broker email RFP submissions - All of these cannot be framed just as a NER problem! In this insightful article, our very own Pragnya Suresh outlines how Ushur solved this using a novel Ontology-guided information extraction process. #dataextraction #naturallanguageprocessing #intelligentautomation #ontology #healthcare

Is your Neuro program profitable? It is a simple question to a complex issue. I was reminded of this yesterday when a new customer of ours setup a meeting to talk about the financial health of their program. You see, they replaced their telestroke vendor with Sevaro and are now looking at the ability to bill for our services. Did you know many of our competitors either don't document in the hospital's EHR or they document but privilege so many neurologists that paneling the group with all insurance providers is simply not doable. Both of those lead to an inability to seek reimbursement for the services. Many of our customers see a 300-500% ROI when they switch over to Sevaro. Our small panels of neurology experts, fast response times and expert operational leaders all lead to a healthier financial outlook for our customers.

📣📰🗣️Take a moment to read the latest on one of our WVU Innovation Corporation tenants, GATC Health and their great strides in AI drug discovery. #letsgooo #westvirginia #WVU #WVUMedicine.

Across many customer journeys in Insurance and healthcare, we constantly come up against information retrieval challenges. It could be a simple claim submission process (FNOL) involving emails from agents , extracting medical information from patient notes or a more complex use case like extracting information from broker email RFP submissions - All of these cannot be framed just as a NER problem! In this insightful article, our very own Pragnya Suresh outlines how Ushur solved this using a novel Ontology-guided information extraction process. #dataextraction #naturallanguageprocessing #intelligentautomation #ontology #healthcare

Hot off the press! Our paper is now published in Social Science & Medicine (IF: 5.4). This is a joint work with Jinsui Zhang, Min Hu, Wen Chen from Fudan University and Yusheng Jia from University of Rochester Medical Center. In this paper we developed a novel Discrete Choice Experiment (DCE) to optimize regulatory schemes to enhance deterrence against medical insurance fraud by enrollees. We also show that using theory as a guide can help avoid missing important attributes in DCE design. https://lnkd.in/gD4Rxeu7 Macquarie University Centre for the Health Economy

🎄 𝟭𝟮 𝗗𝗮𝘆𝘀 𝗼𝗳 𝗖𝗵𝗿𝗶𝘀𝘁𝗺𝗮𝘀 𝘄𝗶𝘁𝗵 𝗔𝗡𝗭𝗜𝗜𝗙🎄 For today only, non-members can access the premium article, 𝗪𝗲𝗶𝗴𝗵𝘁 𝗹𝗼𝘀𝘀 𝗱𝗿𝘂𝗴𝘀 𝗮 𝗱𝗶𝗹𝗲𝗺𝗺𝗮 𝗳𝗼𝗿 𝗶𝗻𝘀𝘂𝗿𝗲𝗿𝘀 𝗮𝗺𝗶𝗱 𝗰𝗲𝗹𝗲𝗯𝗿𝗶𝘁𝘆 𝗵𝘆𝗽𝗲. Explore how insurers are navigating the rising demand for drugs like Ozempic, balancing short-term costs with potential long-term benefits, and responding to evolving medical and consumer trends. 💡 Don’t forget! On the 12th day, we’ll be giving away two free ANZIIF memberships for 2025. Tag someone you’d like to see thrive in their career in the comments below. 👉 Read the article today: https://okt.to/TRL36k #ProfessionalDevelopment #ANZIIF #Insurance #ozempic