Brian Woods MD

Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

1

Through the Cliff Appreciates program, UH CEO Cliff A. Megerian, MD, FACS, Jane and Henry Meyer Chief Executive Officer Distinguished Chair, likes to recognize our non-physician caregivers who stand out for living the UH values with the Bravo Awards. Today’s caregiver spotlight focuses on Jason Pirtz, RN, who is being recognized as a Bravo Award winner for providing service excellence and demonstrating an outstanding commitment to patient care and engagement as Chief Operating Officer (COO) for UH Cleveland Medical Center. Amidst a hectic schedule, Jason noticed a patient looking lost and took the time to personally escort him to his appointment at UH Harrington Heart & Vascular Institute. This thoughtful action made a significant impression on the patient, who was so moved by the experience that he wrote to our CEO to express his gratitude. The patient's note highlighted the exceptional level of care and concern demonstrated by Jason, which he has shared with many others. By leading with such compassion and dedication, Jason not only provided excellent service but also positively represented the ethos of patient engagement at UH. We decided to chat with Jason to learn more about him and how he lives the UH values: As COO, how do you live the UH values? Working for a large healthcare organization brings amazing opportunities, but I don’t believe that we can provide the best care possible for the patients we serve without first focusing on teamwork and a consistent drive toward service excellence. Ultimately, I feel that it is my responsibility to create an environment of teamwork that sets our caregivers up for success. How do you support the needs of the various caregiver teams? This is one of my favorite questions to answer as I feel the ultimate commitment to all of UH Cleveland Medical Center’s caregivers. Whether it’s advocating for new technology, creating a safe environment, streamlining workflows or upgrading our facility, everything we do is important to our mission. I live by the motto that “If you are not serving a patient then you better be serving someone who is.” What do you like best about working at UH? I have a great appreciation for the relationships that I have built within the organization over the past seven years. The caregivers who I work with are not just employees -- they are my friends and colleagues. I trust them, and these relationships are the reason why we are able to do the very challenging work that we do. What’s been your most memorable experience at UH? I think my most memorable moment was UH’s response to the COVID-19 pandemic. When I was very new in my role at UH Cleveland Medical Center, I had the opportunity to serve as Chief Operations Officer within the Hospital Incident Command structure. I was so proud of our caregivers and their unwavering commitment to our community during that time. It was absolutely amazing! #UHProud #serviceexcellence #teamwork

75

7 Comments

Proof of Purpose; PDPs kept afloat Good for Manufacturers, too? The intricacies of IRA Part D benefit redesign dramatically reshape the OOP for millions of beneficiaries, reducing financial toxicity and raising utilization (I will post to past non adherence figures in comments) Unlike MA PDPs, freestanding PDPs can’t shuttle money over from the medical benefit to moderate premium increases, so some speculated that PDPs would fail. I commented several times that given this administrations view of the private market exemplified by MA that was highly unlikely. And after all PDPs are holding up half the benefit. CMS moves forward. “CMS is also announcing a voluntary demonstration program for standalone prescription drug plans (PDPs). The Part D Premium Stabilization Demonstration is designed to test whether additional policy changes stabilize year-over-year changes in premiums for participating standalone PDPs, leading to more predictable options for beneficiaries during the initial implementation of the IRA’s) benefit improvements, creating more gradual enrollment changes… Under the voluntary demonstration, there will be a reduction in the base beneficiary premium of $15 for all participating PDPs, combined with a year-over-year plan premium increase limit of $35 and narrowed risk corridors..” Thanks Tom Thoughts on implications, such as spillover from reducing headwinds, moderating adoption of narrower formularies and networks? If so possible plus for Phrma —not to mention if it slows down MA train with attendant Part B drug prior auths. #PartD #PDPs

5

2 Comments

#RepLloydDoggett from Texas nails it in his opening remarks on CMMI models, MA plans AND Medicare Physician Fee Schedule. Thankyou Rep. Doggett! House Ways and Means Subcommittee on Health Hearing: “Improving Value-Based Care for Patients and Providers” Wednesday, June 26, 2024 Ranking Member Doggett: “While I support paying for value over volume, efforts to achieve that have so far experienced very mixed results. Over the last decade, CMMI has launched more than 50 models, with only six delivering savings and two demonstrating improved quality. One of the primary challenges in achieving genuine value-based care is that we have struggled to define and measure value. Some of us sat in this same room and heard the grand promise of a Medicare Advantage (MA) program that would give us the greatest value by expanding beneficiary choices, reducing health inequities, and saving taxpayer dollars. MA plans aren’t just getting paid more to deliver the same care you would receive under traditional Medicare. They are often covering less care. MA plans continue to interfere with the doctor- patient relationship through burdensome prior authorization (PA) requirements, step therapy, and other management tools. For the care that is delivered, many physicians face inadequate payment. While some alternative payment models (APMs) appear to show greater promise and achieve the outcomes we aim for, they must be carefully designed to avoid repeating the failures in MA. These models also should not serve as the back door to greater privatization of Medicare. As part of today’s discussion, we do need greater attention on improving the Medicare physician fee schedule (MPFS). Providers rightfully want to see payments keep pace with inflationary costs. We also continue to underpay primary care providers, who offer some of the most important and high value preventative care. And of course, MA plans, which now cover more than half of beneficiaries, may reimburse less than the MPFS. To achieve greater value, payment reform must include MA reform.”

6

5 Comments

On October 8th, U.S. News & World Report released its annual rankings of Children's Hospitals, called "Best Children's Hospitals". It is a 174-page report describing the methodology and data tables which I scanned through. Appendix C-10 has the data on Pediatric Pulmonology which I took a deep dive into. In the attached carousel, I have recreated two datasets that matter. If I were to shop around for a hospital for my care, what really matters to me is the outcome data for a particular condition I am seeking care for and not the reputation score. However what separates the top-ranked "Best Children's Hospitals" is their reputation scores, not the outcome scores for selected conditions as in asthma here. It's a different matter whether the outcome scores used in the rankings are good measures. We will discuss them in another post. What are your thoughts? Feel free to like, share, and comment. #healthcare #hospitals #physician

5

Here’s your recap of last week’s health IT news 🗞️ 👇 🖊️ AI Ambient Scribes • CHRISTUS Health + Abridge: The 15,000 provider Texas health system adopted the ambient scribe enterprise-wide.    • Tampa General Hospital + Nuance Communications DAX Copilot: Over 500 providers at the health system will begin utilizing the AI ambient scribe.    • Texas Oncology + DeepScribe: The statewide oncology practice adopted the AI ambient medical scribe. (ed. note: scribes continue to be hot!) ☎️ AI Contact Center • Clearstep: The AI conversational chat vendor launched a new feature allowing patients to self-schedule specialist visits. 📊 Data & Analytics • InterSystems + CLEAR: The cloud-based patient data service is integrating the identity technology to expedite access to patient records.    • WakeMed + Bamboo Health: The health system is adopting the data interoperability and encounter notification service. 🥼 Clinical Decision Support • University Hospitals + Aidoc: The Cleveland-based health system is implementing the AI clinical decision support platform across 13 of its hospitals and additional outpatient locations. 🧑‍💻 Virtual and At-Home Care • University of South Carolina School of Medicine + Rimidi: The hospital group and an affiliated multispecialty clinic are adopting the remote patient monitoring platform to reduce complications from postpartum hypertension.    • Mount Sinai Health System + HealthSnap: The medical center announced a new remote patient monitoring and chronic care management program in partnership with the virtual care management platform.    • Wheel: The telehealth company released a new AI-driven virtual care platform designed to enhance the patient experience and offer resources to help partners scale their virtual care services. 💬 Patient Engagement • CipherHealth: The patient engagement solution focused on patient rounding released a new AI summary tool.    • DexCare: The care orchestration platform completed a $75M series C funding round 🩼 Durable Medical Equipment • Better Health: The medical device and peer support network completed a $14M funding round. 🧠 Food for Thought: • Silicon Valley Bank released an interesting report on the state of investment in AI in healthcare, including stats on AI usage at healthcare organizations and the impact of leveraging AI on startup valuation. https://lnkd.in/em7AfivT    • The journal Critical Care Medicine published an editorial on an “in clinico” evaluation of a machine learning-based early warning system to predict in-hospital deterioration. We found it to be an interesting look at the actual impact of a model’s deployment on care processes and patient outcomes in a critical care setting. https://lnkd.in/eQhZbVKu

47

3 Comments

Join Eric Lucas, Jonathan Mason & Georgia Green, MS, CHFP for a webcast on 8/27 - Medicare Regulatory Update: 2025 IPPS Final Rule. We’ll discuss the latest updates for hospitals and cover topics including an evaluation of the IPPS final rule key areas, reimbursement shifts and data trends identified in the IPPS final rule data, and next steps and factors to consider because of the final changes, including the mandatory TEAM model. #healthcare #hospitals

5

Want to know exactly what Medicare will pay your hospital for a specific admission and the impact a CDI query will have on the case? Google your hospital's "CMS provider number" -Systems may use the same number for multiple hospitals so you might need to dig a little Go to this website: CMS.webpricer.gov and click on "Inpatient PPS" Enter the following: Your hospital's provider number that you Googled Admit & discharge date: make them up to a recent time period Total charges: put 10K if unsure, it won't matter except for outlier cases Covered days: put enough days that cover the length-of-stay DRG: Google "MS-DRG Relative Weight table 5" to get a list of all DRGs Click "Estimate" and you'll see your hospital's payment on the right. You can also scroll down and see your hospital's "cost-to-charge ratio", which is a factor in outlier payments. You can click "Edit Claim" and enter higher charges if you want to see when outlier payments start to kick in or try different DRGs If you want to see the impact of a query that takes a case from a "W/O CC/MCC" (without complication/comorbidity, major complication/comorbidity) to an "MCC" (major complication/comorbidity), enter the MS-DRGs that go with each of those, so DRG 379 for w/o cc/mcc and DRG 377 w/MCC in the GI bleed examples in the slides. The attached slides show a snippet of the CMS relative weight table with GI bleed highlighted to show you the different relative weights of the three severity levels for that DRG. Other DRGs may have just one or two severity levels Next slide is a snapshot of the CMS CC/MCC list with "viral pneumonia" highlighted as a major complication/comorbidity (MCC) Last two slides show you how the payment is calculated for a hospital (UCLA in this case) for the GI Bleed MS-DRG and the impact of a query for "viral pneumonia" that increased the severity from a "WO CC/MCC" to "W MCC" This isn't just for adult patients. There are 12 states that pay Medicaid by MS-DRG and plenty of commercial payers in every state that pay by MS-DRG. Contact Pediatric Resource Group (PRG) to help you develop or optimize CDI for your pediatric/neonatal patients. Don't have peds? We have an adult consulting division as well called Physician Resource Group (PRG) #CDI #revenuecycle #hospitalfinance #MSDRG #CFO #clinicaldocumentation

35

1 Comment

I hole heartedly agree Benjamin Schwartz, MD, MBA. Anywhere else in an economic system, innovators who can deliver a better product at lower costs are almost always rewarded with greater market share, and frequently set the direction for the future of a product or industry. Not so in healthcare. I think that Terry Adirim, MD, MPH, MBA (below) hit the nail on the head when she references for-profit health insurers in the mix. Although policies have been enacted with the idea of providing better healthcare at lower costs, they have always given the job of administering those policies to a middleman (insurance companies) whose motives are at odds with the objective they claim to be administering. Profit! Innovation is not in the best interest of the payer. They profit through the inefficiency of the system. Until this lack of alignment between quality patient care at low costs and for-profit health care plans is addressed, process innovation and improvement will only be able to nibble at the edges.

2

How do we equip and support great clinical leaders to also be great business operators? I had the opportunity to learn some of the answers in this great session today with Mark J. Palmieri at the The Council of Autism Service Providers Annual conference in Fort Worth. Thanks, Mark, for sharing your insights from CCSN: The Center for Children with Special Needs!

31

1 Comment

The Association of Healthcare Value Analysis Professionals (AHVAP) celebrates Elizabeth Eisenberg, MSN, RN, CVAHP from Scripps Health for commitment to excellence in the specialty of healthcare value analysis! Liz has signified this commitment by signing the official Association of Healthcare Value Analysis Professionals (AHVAP) healthcare value analysis pledge. To learn more about the Association of Healthcare Value Analysis Professionals (AHVAP) Commitment pledge: https://lnkd.in/gqEWPBue. #AHVAP #valuebasedcare #excellenceincare #valueanalysis

7

CMS just issued the RADV audit target list for Payment Year 2018 (with premium claw backs). 60 MA plans selected for audit, instead of the usual 30. CMS claims that claw backs will begin in mid-2026. Plans need to act immediately to: Consider self-identifying encounter data submissions pursuant to the Overpayment Rule. It's better to refund money to CMS rather than allowing those errors to be used as extrapolated claw backs for all enrollees. MA plans may want to conduct a mock-RADV audit on 2018 encounter data submissions to inform the 2026 bid development process. A mock-RADV would limit the refund of identified overpayments just to those records included in the mock-RADV audit.  If the Payment Year 2018 goes off as CMS has indicated, premium claw backs will occur in 2026. And if the PY 2018 claw backs occur, then there is PY 2019 and subsequent years for the plans to deal with. CMS has accelerated its RADV process beyond the “tortoise” pace that had been apparent. This means that all MA contracts (not just the 2018 audit targets) need to dramatically improve both data integrity and data accuracy of their encounter data submissions.

45

💫 MEDICATION ADHERENCE SUCCESS STORIES VOLUME 1 💫 The Family and Children's Services of Oklahoma (FCSOK) serves over 100,000 people every year in mental health services and generates nearly $100 million dollars from #Medicaid and #Medicare¹ alone which averages $1,000 billed against each patient. – CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month ¹fcsok. org/news/archived-reports/ This case study presents a replicable blueprint on how to utilize the validated MMAS (Morisky Medication Adherence Scale) in a large format setting. Directly integrated into EHR (Not a separate platform or screen), the intervention is smooth and dynamic. We have several methods of delivery available to all HCP. -Our own platform -partner provided -technology transfer -api/webservice "The Questionnaire is a 16 question composite of the Morisky-8 (MMAS-8) and Drug Attitude Inventory. Secondly, all department in the Adult Mental Health Division, except PAP and Pharmacy, screened for adherence at each visit. The screener consisted of a mandatory question embedded in the electronic health record’s (EHR) individual service documentation. If a client identified as not taking medications as prescribed, a mandatory selection of adherence barrierswas prompted. Lastly, an Adherence Barrier Questionnaire was administered to clients in the Medication Clinic to identify the frequency common barriers were contributing to missed doses in a given month." (P.11 shows the MMAS built directly into the EHR) The MMAS has been integrated into many platforms like CVS HealthCVS Specialty vendor Asembia into their Asembia-1 platform, being used since at least 2016. New #clinicaltrials .gov and research studies DAILY from large institutions globally. Nearly 500 large scale to date with a 6 year pipeline for the largest ones and over 100 active. I will be at HLTH USA Las Vegas to demonstrate the power of this tool in real world practice. See how it can improve your metrics and the health of your patients. The Scale is just the tool, the interventional part is the magic.

18

1 Comment

Healthcare investment market is interesting yet challenging…

2

Mark Your Calendar: December 17th! Join me at 10:00 AM PST | 1:00 PM EST for the Medicare Quarterly Updates Webinar - 4th Quarter hosted by McVey Seminars. Stay informed with the latest Medicare updates! Register today: https://lnkd.in/gmgzbjSg Let’s navigate these updates together! #McVeySeminars #TerryTuesday

29

There are new options for a certain category of pain blocks, the overall takeaway is that anesthesia providers continue to be faced with pay cuts from a Medicare conversion factor perspective. https://lnkd.in/ekD5CA2i

8