Grant Lunney

My takeaways from the Reuters Events Healthcare #digitalhealth24 in San Diego this week. Please pardon any discrepancies 😀 or confusion this morning - Alaska Airlines delayed me for four hours so I could re-live my college days and get to bed at 1:50 am. Here are some highlights: - AI has a lot of potential in health systems, but ethical concerns and risks are top of mind and being wrestled with daily. - Change management is the biggest challenge, not the technology itself. - Tech leaders understand the importance of focusing on problems rather than solutions. Will this mindset spread throughout the industry? - Endeavor Health is a great example of a smart health system with a clear progression from research to enterprise-wide execution. Thanks Justin R. Brueck - The role and definition of the consumer in healthcare is still a topic of debate, especially when it comes to healthcare and services they would rather not spend time or money receiving. No one identifies as a patient! #digitalhealth #healthcare #AI #healthsystems #consumerhealth #healthcareinnovation #changemanagement HCT Consulting Group

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UnitedHealth Group is the latest Medicare Advantage provider to file another lawsuit against CMS challenging a drop in their Medicare Advantage star ratings, purportedly based on a single eight-minute call. According to their complaint, they stand to lose tens of millions in revenue due to this lower rating. "Unless corrected by this Court, that downgrade will misinform millions of current and potential customers...[t]he substantial adverse impact ...is imminent, because the Star Ratings will be published for customer consideration on or about October 10, 2024." They go on to argue that as lower-rated plans tend to lose enrollees during open enrollment and beyond, the impact will snow ball, further impacting their bottom line and revenue forecasts. For some background: the MA star rating system was introduced in 2007 and was supposed to be designed it to provide beneficiaries with a quick gauge of plan quality across categories like clinical outcomes, patient satisfaction, and customer service. While United makes it sound like the MA star ratings system is nothing more than a glorified Yelp review, star ratings are based on over 40 performance measures, including clinical outcomes, patient satisfaction, and call center responsiveness with data from HEDIS and CAHPS. Moreover, plans even have multiple preview periods to contest preliminary ratings before they’re finalized​. The star ratings translate directly into billions of dollars for plans like UnitedHealthcare. For instance, the average annual Quality Bonus Payment per Medicare Advantage enrollee in 2022 was $352—a substantial amount when scaled across millions of enrollees. UnitedHealthcare isn’t the first to fight CMS on star ratings. Similar lawsuits from Elevance Health and Scan Health were filed over perceived unfair treatment. UnitedHealthcare’s recent lawsuit and those before it underscore the fact that they’re more than willing to support this rating system when they are able to cash their bonus checks, but are quick to decry it when they receive a downgrade based on “shoddy service” caught in a secret shopper review. UnitedHealthcare would have no issue with these “Yelp-like” ratings if they were raking in five-star bonuses. Now that they’ve been hit with a lower rating due to a call they claim didn’t follow protocol, they’re ready to rewrite the rules. Do I believe the CMS’s rating system is perfect? No, but that’s the system they signed up for and have profited dearly from over the years —and now they're throwing a legal temper tantrum when they didn't get their way. Jeffrey HoganPreston AlexanderWendell PotterPatient Rights AdvocateLee LewisScott Conard, MDJohn TozziSara HansardWilliam SarrailleKimberly CarlesonNelson GriswoldShawn GremmingerKaren van Caulil, Ph.D.Gloria SachdevMarilyn BartlettPeter Hayes

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It’s not enough to be great at billing, optimization of revenue cycle best practices are a necessity in realizing great healthcare financial health. Leveling up strategies heavily revolve around: ✅ Proactive patient collection strategies. 30% of healthcare revenue comes from patient cost sharing. Nobody can afford inefficient and costly patient collections strategies. Up front, with accuracy and transparency, is always best. ✅ Improve registration and eligibility checks. Automate, automate, automate. And then do it every visit, every service rendered. ✅ Develop patient friendly payment plans and options. Even grocery stores are now taking after pay programs. People want options and some people really need them. ✅ Maximize EMR and PM capabilities. If your systems aren’t working for you - and on the constant edge of innovation - they’re working against you. Getting paid quickly and accurately is the mission of any great revenue cycle operation. When you focus on strategies around accomplishing this, you become a well oiled machine. #revenuecyclamagement #operationalexcellence #healthcarefinance

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Provider Data Management (PDM) is super important for both Payers & Health Plans (P1) & Providers & Hospital Systems (P2) - Why? An interesting article. Perfect 👍 & to-the point. Click the Link below 👇 Summary Mobilizing Big Data To Support Healthcare Providers Even at the best of times, managing provider data can be a complicated business. Say that each provider has around 140 data points. A practice with 10 providers and 20 health plan contracts might have to manage around 28,000 data points each quarter. Across the US, such information is gathered from over a million providers and from more than 6,000 hospitals and clinics. Health plans further transfer provider claims data to multiple downstream applications and provider systems. Talk to us on LowCode & AI Powered Newgen PLM / PDM Software Manish Jaiswal 646.644.3049 https://lnkd.in/ezwmRrKb

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A recent survey found that nearly half of healthcare leaders (49%) say their patient data is stored in fragmented, siloed systems. Curating a complete and trusted longitudinal view of the patient journey from these fragmented, siloed systems is often inhibited by the seminal need for accurate patient identity matching—knowing who the data belongs to at every touchpoint. Our CEO Clay Ritchey details critical steps healthcare organizations should take to elevate the quality of healthcare data as data volume grows faster than ever. Read the article now via MedCity News: https://buff.ly/3BXPaq8 #IdentityManagement #Healthcare #PtExperience #ImprovedOutcomes #WhoIsWho #DataFidelity

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The California Office of Health Care Affordability has recently approved a requirement that all healthcare providers report their annual operating expenses. If those expenses increase more than 3.5% (eventually lowering to 3%) in a year, that provider will be fined, ironically increasing their expenses. The state claims this regulation is aimed at protecting consumers from high healthcare costs. This is the same State of California that recently raised all healthcare workers' minimum wage to $25 per hour (up from $15.50).  For our health system, that results in a $30 million annual cost increase and a 7.5% increase in our salary costs. This is also the same state that passed an unfunded mandate that requires our system to spend about $1 billion to replace a hospital building that they feel is at risk from damage in an earthquake. And it’s also the same state that increased the cap on medical malpractice lawsuits…and has authorized utility companies to raise their rates 15% per year.  So, with all of these unfunded requirements and policies that dramatically increase providers' costs beyond their control, how exactly does the state suggest that we limit our expense growth to 3% per year?  Healthcare cost inflation has already been running at more than 5% before any of these new requirements took effect. Perhaps if California wants to get serious about reducing the cost of healthcare they might look at the managed care plans. The most recent data I could find from the California Health Care Foundation indicates that California managed care companies made $222 billion in 2020. What direct value did these companies provide to the health of our communities? Meanwhile, hospitals and physicians are providing direct patient care and struggling to survive- especially systems like Kaweah Health that serve a high percentage of Medi-Cal (Medicaid) and Medicare patients.  On a side note, the governor did sign a new managed care organization tax into law this year, which was promised to increase Medi-Cal reimbursements to providers, but all signs suggest that he now intends to use those proceeds (nearly $7 billion) to fill holes in his budget's general fund deficit and will not be providing Medi-Cal rate increases. I would humbly suggest that if the state is genuinely concerned about its residents' cost of living, they might look at the state income tax (highest in the country), its gas prices (highest in the country), the essentially unaffordable housing costs, or countless other factors that will have a larger impact on individuals' pockets than beating up healthcare providers with laws that don't make any sense. #hospitals #california #healthcare

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How are ACO benchmarks calculated? Like everything in healthcare, it sounds simple in theory but gets complicated fast. Try matching CMS benchmark numbers and you'll find the devil is in the details - details that translate to significant dollars. One major component of the ACO benchmark is the county-level rate book. I've been analyzing the ACO REACH (and DCE) Age and Disabled Prospective County-level rate book in Texas, comparing them with Medicare Advantage Rate Book data (go check out my previous post [1]). An interesting pattern emerges: ACO REACH rates seem fairly flat over the years while MA rates have been steadily climbing. Why? The ACO REACH Rate Book evolved from the MA rate book methodology. As CMS explains [2]: "The ACO REACH/KCC Rate Book removes factors applied to the MA Rate Book that are not relevant in the ACO REACH and the KCC Models (such as fee-for-service [FFS] spending quartiles, quality bonus payment percentage for star ratings), adds components of Medicare FFS expenditures that are not included in the MA Rate Book but are relevant in the ACO REACH and the KCC Models (such as hospice services), and mirrors ACO REACH eligibility requirements" These seemingly "minor" (?) adjustments create substantial differences. This raises intriguing questions: - What does it mean when a county shows rising MA rates but flat ACO REACH rates? - Does this create regional arbitrage opportunities for ACO-to-MA conversion strategies? - How do these compare to MSSP benchmarks? The analysis continues... 📊 By the way, ACO REACH (formerly DCE), CKCC, and MSSP rate books are now in the mimilabs data lakehouse, organized by the performance years! No need to dig around the CMS website for these numbers! [1] https://lnkd.in/e4YWja5Z [2] https://lnkd.in/eMByTA9f #aco #acoreach #benchmark #ratebook #regionalrate

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Update to MA 2025 Final release ( more details are still required). The final (4/23/24) introduces changes to the regulations concerning agents, brokers, and Third-Party Marketing Organizations (TPMOs) in several areas: Unified Compensation Framework: The new regulations implement a unified compensation structure for agents and brokers across all plans. A single compensation rate is set for all plans, updated annually, which also includes a revision of the scope of items and services within agent and broker compensation. Separate payments for administrative services by agents and brokers are eliminated (administrative is defined but more details coming). Oversight and Compliance: Enhanced oversight measures are introduced to ensure that agents, brokers, and TPMOs (includes FMO’s) comply with the updated compensation structures and marketing rules. TPMO Marketing and Data Privacy: TPMOs are now subject to stricter marketing and communication rules. The final rule prohibits TPMOs from selling or sharing personal beneficiary data collected during marketing activities without explicit beneficiary consent. A new one-to-one consent structure is required, where TPMOs must obtain explicit consent from the beneficiary for each TPMO that will receive their data, ensuring more transparent and controlled use of beneficiary information. Prohibitions on Overrides: The regulations explicitly prohibit compensation structures that include additional payments known as "overrides" for TPMOs, which could influence the marketing and enrollment practices in favor of higher-paying plans. As we all know this will need further evaluation but recordings; trainings; portals etc will all be included in the total capped enrollment comp. #MAfinal2025 #medicareadvantage

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At Professional Healthcare Resources we are not only healthcare providers, we are patient advocates who empower patients with the knowledge they need to make the best healthcare decisions for themselves. The IMPACT Act (Improving Medicare Post-Acute Care Transformation Act) emphasizes patient choice in the context of post-acute care, promoting the idea that patients should have a voice in selecting their care providers. Specifically, the Act includes provisions related to patient assessments and data collection that support informed decision-making. For the official text, you can check the following sections that pertain to patient choice: Section 3: Focuses on quality measures and how they relate to patient preferences. Section 4: Discusses the importance of patient engagement and choice in care planning. For the complete text, visit the U.S. Congress website or the CMS website. If you need more specific information or a summary, feel free to ask! #ProfessionalHealthcareResources #HomeCare #wellness #HealthCare

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Top 3 Compliance Mistakes Telehealth Providers Make (And How to Avoid Them) Telehealth has transformed healthcare, but if compliance isn’t prioritized, it can lead to costly issues. Here are three common compliance mistakes and how they can impact healthcare providers: 🚫 Mistake 1: Using Non-Compliant Telehealth Platforms Why It’s a Problem: Many providers continue to rely on platforms like FaceTime or Zoom, thinking they’re enough for secure telehealth services. However, as pandemic-related exceptions are phased out, healthcare providers must ensure their platforms are HIPAA-compliant to avoid data breaches and hefty fines. 📉 Scenario: Imagine a small clinic uses a popular video conferencing app without checking its compliance status. Following an audit, they discover that patient data was exposed due to weak security measures, resulting in fines and loss of patient trust. 💡 Solution: Transition to HIPAA-compliant telehealth platforms with robust encryption, authentication, and audit capabilities. 🚫 Mistake 2: Failing to Regularly Update Policies and Procedures Why It’s a Problem: Telehealth regulations and technology change frequently. Some providers set up their telehealth operations and assume that no further updates are necessary. This can result in outdated security measures and non-compliance with new regulations. 📉 Scenario: A healthcare provider, confident in their initial compliance setup, neglects to update their telehealth protocols for two years. When they undergo a compliance check, they realize their procedures don’t align with the latest regulations, leading to expensive fines and a rush to update systems. 💡 Solution: Conduct regular audits and refresh your policies to keep up with regulatory changes and emerging security risks. 🚫 Mistake 3: Overlooking State-Specific Telehealth Regulations Why It’s a Problem: While federal laws like HIPAA are essential, many providers overlook the unique telehealth rules in different states. Failing to adhere to state-specific regulations can lead to licensing issues and denied reimbursements. 📉 Scenario: Picture a provider expanding telehealth services across state lines without verifying that their practitioners are licensed in those states. A compliance review reveals this oversight, and they are forced to halt operations in that state and pay fines. 💡 Solution: Research and comply with state-specific laws before expanding telehealth services to new locations to avoid legal and financial setbacks. Preventing these mistakes requires a proactive approach to compliance. Stay tuned for the launch of my Telehealth Compliance Consultancy to learn how expert guidance can help you avoid costly risks and safeguard your practice. #TelehealthCompliance #HealthcareCompliance #HIPAA #DataSecurity #HealthTech #Telemedicine #HealthcareRegulations #TelehealthMistakes

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🔍Is your behavioral health treatment strategy reactive or proactive? Starting May 7th, providers and patients can proactively measure treatment and gain insights into symptom severity with our new Behavioral Vital Signs™ report. As a provider, you'll get a comprehensive PDF report via secure message or right in your EHR. This includes trends for clinically validated surveys, actionable self-report data, and even intelligent passive sensing insights for the last 30 days. As a patient you will receive the same report in the Health Rhythms app, where you can share it with your wider care team and securely review them month over month. It's time to improve our mental health measurement capabilities to enhance treatment strategies and improve outcomes. #DigitalHealth #MentalHealthCare #HealthcareInnovation #PatientCare #healthrhythms #bvs #behavioralvitalsigns

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What are the hardest Part D Star Measures?   As part of the 2025 Star Ratings release this year, CMS also posted a couple tables containing the 2022-2025 Average Star Rating by Measure.   The hardest measure, defined by the lowest average Star score, is D12 (Statin Use in Persons with Diabetes (SUPD)). It is the only Part D measure with an average below 3 Stars in the past two years. 

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Early returns from the new 7/1 hospital transparency requirements show more organized data and more audits. Yesterday, a hospital was just fined $871K by CMS. Carol Skenes and I go into more detail in the blog post below. In short: we're seeing CMS establish the infrastructure for automated enforcement via website folders (TXT records), much like a red light camera would on your way to work. The hospital fined yesterday was found to be out of compliance for the old standards and not having their pricing listed on their website correctly. Previously, CMS audited 200 hospital files per month and sent out almost 3,000 individual notices to hospitals from 2021-2023. We'll know more about how these numbers are increasing soon. Link to blog: https://lnkd.in/gAZhBq3b

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The V28 model means big changes for reimbursement methodologies and MA capitation rates. For 2024 dates of service, V28 will be used at 67% before being fully phased in at 100% for 2025 dates of service. What else? 💡 The number of HCCs have increased from 86 to 115 💡 2,294 ICD-10 codes that no longer map to an HCC have been eliminated 💡 268 diagnosis codes that map to HCCs have been added RAF scores will be affected in 2 major ways: 💡 The removal of 2200+ ICD-10 codes means that some diagnoses previously used to calculate RAF score will no longer be used and 💡 The constraining of HCC coefficient values means that related HCCs are assigned the same coefficients It's even more important now that plans are hyper-vigilant with coding and supporting documentation to ensure compliance under the new model. For more info, check out our post on all things #V28: https://lnkd.in/e7USSR-Y #riskadjustment #HCC #ICD10 #OIG #CMS

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📢 Medicare Telehealth Waivers: What's Next? As the end of the year approaches, Congress is still deciding whether to extend, modify, or let the temporary Medicare telehealth waivers expire. A new study in Health Affairs examined 2022 Medicare claims, revealing significant insights into who could be most impacted by changes to telehealth policy. 🔹 Key Findings: - Female physicians, PCPs, psychiatrists, and urban providers are among the highest users of telehealth. - Psychiatrists are particularly impacted—23% deliver nearly all services via telehealth. - Interestingly, urban areas see more telehealth use than rural areas, challenging the assumption that telehealth primarily serves rural populations. HR 7623, the Telehealth Modernization Act of 2024, may extend these waivers by two years. This decision will have a considerable impact on how mental and behavioral health services are delivered moving forward. Let’s see what happens next for telehealth! 🩺✨

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Health Alliance Plan (HAP) is using AI to revolutionize its call centers. On The Bright Spots in Healthcare podcast with Eric Glazer, Mike Treash The Senior VP and Chief Operating Officer at Health Alliance Plan shared how they cut call wait times from 2 minutes to 5 seconds while increasing accuracy. Instead of cutting staff, they reinvested in closing care gaps and re-enrollments. HAP’s approach shows how tech can enhance service and team morale. #HealthcareAI #CallCenterInnovation #ProfitCenterTransformation

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It’s not your imagination - the relationship between providers and payers are deteriorating and you’re not alone. 📈Over 50% of healthcare providers now feel their payer relationships are somewhat or mostly negative. 📈 Rising denials rates are leading the relationship demise and providers believe payers are systematically finding ways to deny claims and delay reimbursement. Providers are adding staff and increasing costs at the hands of a poor relationship which is driving frustration. 📈 75% of providers believe pricing and claims processing behavior transparency would improve the relationship. 📈 Only 7% of providers believe AI is going to improve things in the next three years. With limited solutions to get out of a bad deal once you’re in a contract, it’s clear that who you participate with increasingly matters. Having access to people who can make decisions, treat you fairly as a provider and help you navigate claim challenges is critical to feeling network participation is a win / win. #healthcarefinance #revenuecyclemanagement #healthcarecontracting

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70% of healthcare execs haven’t noticed true cost reductions/ROI when implementing digital health solutions. * * * * Sign up for my free healthcare newsletter at www.HealthcareAndy.com. * * * * These results come from an EY Health Pulse Survey, where 100+ payer and provider execs were asked about the state of digital health. I’m not going to sugarcoat it, these are not great results at face value. In order for digital health to persevere over the long-term, we need bulletproof ROI, net of the digital health fees. Super hard to measure when ROI includes "productivity" or even "ER visit reductions" because there's a million reasons someone goes to the hospital for chronic and acute issues. Now to be clear, I'm not a digital health hater. We’re still “early-ish”. We can’t forever use that excuse, but the industry is objectively young relative to the size and complexity. And like I've said in the past, optimism is the only pathway because pessimism leaves us with the status quo. For me, I continue to believe site of care savings is the most predictable and reliable strategy to focus on. That’s why I believe home-based care for certain services is the correct approach. The problem with home is that unit economics can be challenging, logistics are very complex, and not every patient treatment should be done at home. But others have different opinions (investments or companies they work for). What do you think? - - - - Credit: EY Health Pulse Survey

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