Sandra Lukic - Dapoigny

Value based care (VBC) 1.0 language was heavily oriented to language like "disruption". This language was like a punch in the mouth and was effective at building awareness of new opportunity - but disruptive punches to the jaw don't sound like a very attractive end state. It sounds pretty painful, and maybe that is one reason why VBC adoption has stagnated. VBC 2.0 needs to be about integration and partnership so that we can start to bring real value to patients and the provider organizations who serve them - and do that at scale. The pre-eminent leader in health plan clinical guidelines coming together with the most innovative AI provider of utilization management technology is a perfect example of this new paradigm. Kudos to the MCG Health and Cohere Health teams taking a leadership role to make the health care system work better for all.

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To thrive in the evolving #MedicareAdvantage landscape, change is essential. The next 3-5 years will require more than just best practices — #MA plans (and vendors) must rethink products, provider alignment, and internal infrastructure as we adapt to #StarRatings, #Compliance, #Interoperability, #PartD and other changes.  Leadership is not a title, leadership is hard work. And the immense change we face changes the work of leaders. As #Stars #PlanPreview 2 approaches, here are some suggestion to help mobilize for success: 1️⃣ Identify Executors and Thought Partners Recognize the unique strengths in your leaders—whether they're brilliant operators or visionary designers. Align them accordingly to drive change effectively. Deploy both teams in parallel to first design, then implement, the immense change that looms.    2️⃣ Find the Change Leader Look for an executive who knows the operations, embraces details, navigates ambiguity, and collaborates across teams. This is key to steering your organization through the unavoidable uncertainty that accompanies change. 3️⃣ Bring Leaders onto the Field Leaders need to re-engage with the service area, with staff, and with details. Ditch time-consuming-to-prepare powerpoint bonanzas full of information about the OLD PROCESSES, and replace with less formal, more detail-oriented problem solving where leaders can find and spot new and emerging issues, sense distress and confusion, and identify those resisting change. Reset the tone of governance and oversight meetings to skip the happiest news and bring the problems into the room to help get the organization through to the other side. Change is, indeed, hard. But we, as good leaders, can make it easier. #LetsRoll ⭐⭐⭐⭐⭐  

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At the core of every healthcare system is the people it serves. Whether it's a family navigating eligibility or a provider delivering care, these interactions must be seamless and efficient. A state’s healthcare system must be accessible, responsive, and focused on delivering real outcomes. Transforming the Medicaid experience is a vital shift toward a healthcare system that places the needs of individuals at its core, driving meaningful, lasting improvements for families and communities. https://lnkd.in/gf7HVcFH #Medicaid #HealthEquity

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Interesting perspective on #TechnologicalDebt in health care by Dave Lamar focused on the provider market, but we seem the same issues within state depts and payers. While good data governance practices are key, there must be a better way to solve this common - if not universal - challenge in health care, if only by offloading some of the administrative responsibilities that require the individual management and administration of no-value-add administrative functions. #healthdata

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Now that our HIT industry has spent nearly 40 years figuring out how to effectively pass data between sites, settings, and institutions of care (and while that journey isn't completely over, we're well on our way), we can finally turn and look farther down the road and consider what's next. In my view, advancing process consistency, agility, and change is that horizon. The BPM community is focused on that challenge, and having recently transitioned into HL7 as HL7 BPM, is squarely trying to take this on. With today's press release, HL7 is truly open-for-business in this space. Thanks to the OMG for nurturing this work along and for HL7 for having made our next home for this effort. So much to do! https://lnkd.in/dAF96g3n

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IT'S ABOUT TIME! How many healthcare professionals recognize the almost unlimited opportunities in the leveraging of SDOH data and information, but don't know where to start? Your solution is here and available! In her new book "The Shift: SDOH Program Design & Operations," Dr. Shannan Swafford provides a comprehensive and insightful guide that is essential for any healthcare organization looking to effectively address the social determinants of health (SDOH). As someone who believes in "a little less talk and a lot more action", Dr. Swafford cuts to the chase in both style and content. This book stands out for its clear and actionable approach to help organizations navigate the intricacies of SDOH program design. Her deep expertise and proven strategies provide readers with the guidance needed to operationalize SDOH initiatives. One of the key strengths of "The Shift" is its focus on the critical importance of SDOH in healthcare and its impact on patient health. Dr. Swafford's expertise and insights into health policies and reimbursement structures are particularly valuable. She outlines how to support SDOH initiatives within existing healthcare frameworks while focusing on improving health equity and patient outcomes. She also emphasizes the need for data analytics while reminding us that behind every piece of data is a person. Overall, "The Shift: SDOH Program Design & Operations" is a must-read for anyone involved in healthcare who is dedicated to making a meaningful difference in addressing the social factors that influence health outcomes. The Shift: SDOH Program Design & Operations https://a.co/d/6oRzMoB #Healthcare #SDOH #HealthEquity #HealthcareInnovation #DrShannanSwafford #NewRelease #HealthcareLeadership #AHIMA #HILeadersareneededhere

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NEW bundled payment model alert! CMS announced Transforming Episode Accountability Model or TEAM - a new bundled payment model starting in 2026. Many equity-oriented features in TEAM: - tracks for safety-net hospitals - social risk adjustment (though details TBD) - mandatory design --> think more uniform participation and care redesign insights that apply to historically marginalized and low SES benes too - quality measures including PROMs (but not quite getting to pre/post to also inch toward appropriateness) Check out a more comprehensive discussion in this article, written together with Joshua M. Liao, Austin Kilaru and other Parity Center team members! https://lnkd.in/eETfWwj2

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🔎 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

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HTI-2 is here. Laboratories will want to take note as there are requirements for use of Laboratory Orders Interfacing (HL7 version 2.5.1) and Laboratory Results Interfacing (HL7 version 2.5.1) for public health reportables (ELR). If you don't yet have HL7 2.5.1 interfaces with trading partners (paper, fax, HL7 version 2.3.1, etc) you should make plans to update interfaces soon. This impacts both senders and receivers of laboratory data. If you are a pathology laboratory, this may impact you if you perform any public health reportables like Creutzfeldt-Jakob Disease(CJD) as it is reportable in many jurisdictions. ONC has webinars. EHR vendors, providers, and those performing specimen collections will want to ensure they send complete information such as Specimen Type, Specimen collection procedures, Specimen Source site and other Ask at Order Entry (AOE) details required by the performing laboratory and/or public health for reportables.

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This article by Heather Landi at Fierce Healthcare is a great start with good insights, but it barely scratches the surface of this new rule by the Office of the National Coordinator for Health Information Technology (ONC). The #HTI2 rule is the first time #payers have a path for certification. In addition, there are requirements for #ai algorithms. If history is any indication, this could really change the game.. There are now certification criteria for: #PatientAccessAPI #providerDirectoryAPI #PayertoPayerDataExchangeAPI #provideraccessAPI and #priorauthorizationsupportAPI

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OIG ALERT: Diagnoses reported only on enrollees’ HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023. Before we dive in here I want to say that I have seen HRAs used appropriately and inappropriately during my time in this space. There can be great value for patients, particularly those with limited access to care and or those reluctant to visit their primary care provider. However there is tremendous risk to the system if these visits are a fragmented approach to care and or not aligned with care planning. What the OIG has identified represents the risks and shows care continuity breakdowns. Ultimately organizations and payers must know their vendor partners because there are some really good ones in this space. Earlier this week the OIG released a really interesting look into Health Risk Assessment, or HRAs. These HRAs are often performed in the home by payers or vendor partners. These should be in depth reviews of the patient and include a host of assessments that often are hard to complete in a condensed visit to a provider office. What the OIG found was that 7.5B or about 2% of all Medicare revenue was tied to conditions captured only during these visits. Is that bad? I don’t know. If these are new conditions and then ultimately incorporated into a broader care plan that improves outcomes then they are a great thing. If they are captured, never shared with the care team, and ultimately used to solely drive revenue with little focus on outcomes then it is bad. I suspect there is a mix of both. If I was at the OIG I would want to take a multi-year look at what was captured year over year only in a HRA as a next step. The report recommends CMS take the following actions. CMS subsequently agreed with recommendation number three but not numbers one and two. 1) Impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments. 2) Conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews. 3) Determine whether select health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies. I am doing some advanced analytics on information in the report for future posts but this is a nice easy read for folks. https://lnkd.in/ehNzzSWu

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Please check out this article on navigating today’s health literacy digital complexities with innovative solutions in Managed Healthcare Executive featuring executive insight from Barry Volin at Managed Care Resource Alliance, Kathleen McQuade Ellmore from Engagys LLC, and Alison Lyne from Ushur.

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🎯 Bridging Product Development and Market Needs in Health Tech Transitioning TunedCare from a D2C to B2B model taught me some (ahem) hard lessons about aligning product capabilities with market demands. In building scalable workflows to handle eligibility files, claims capabilities, and population health data, we contracted for 1.4M+ lives in under a year and secured major channel partnerships with NFP, USI, and Nomi. What stood out most? Success comes when you listen closely to clients, prioritize operational execution, and push for alignment across product, sales, and marketing teams—even when it's uncomfortable. I’d love to hear from founders and operators: What’s been your biggest challenge in ensuring your product truly meets market needs? #healthtech #leadership #gotomarketstrategy #healthcareinnovation #growthleadership

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Last week at #Techweek in Seattle, we discussed converting innovation into income in healthcare - Stead Burwell from Outbound AI, Leslie O'Brien, MHA from One Medical, and Patrick Mauro from Pearl Health shared revenue models they pursue while improving health outcomes, accessibility, and customer satisfaction. Revenue models in healthcare are nuanced. A couple of thoughts: 📈 PMF is still the goldilocks dilemma  – if your problem isn’t 'hair-on-fire' and your solution doesn’t efficiently and precisely solve the problem, attempts at revenue generation, no matter how creative, are no more than rearranging deck chairs on the Titanic. Having worked with and invested in dozens of early-stage companies and vetted 100s more, I’ve personally seen the slow cycle of ‘lack of PMF’ death play out innumerable times. 🏥 Walking into health-tech innovation with a consumer-only mindset can be limiting. Most healthcare solutions (85% of the market) generate revenue on a B2B model. For companies where the end-user is also the paying customer, this alignment advances product/service development. For those solutions that rely on patient adoption but on B2B revenue, companies now have the challenge of ‘servicing’ multiple ‘clients’. In the best-case scenario, this manifests as a slow #sales cycle in which the company must demonstrate adequate adoption and both clinical and financial benchmarks in the target customer BEFORE attracting revenue-generating contracts. This can mean increased cash burn, higher initial cap ex, and a higher investment risk profile due to more potential points of failure. In healthcare and the life sciences, KNOW your revenue generator AND your user (given the US health system's complex stakeholder landscape, some degree of #B2B interface is more than likely). #Product development and #GTM should keep both in mind.

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Behavioral healthcare has many facets. Can your #EHR handle your complex needs? Core's recent blog post shares valid food for thought. 

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Some important lessons learned for anyone with a struggling Hospital-at-Home program or planning to launch one. Avoiding these mistakes can lead to significant success when combined with other best practices.

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