Erkeda DeRouen, MD ✨ Digital Health Risk Management Consultant ⚕️TEDxer

It's wild to think in 2024 we're FIRST seeing the DOJ accuse telemedicine conglomerates of criminal drug distribution. How long have we known about these practices in brick and mortar care...? Answer: decades! Take it from someone who prescribed stimulants and other psychotropics to kids over the years - painstakingly measuring and documenting the need and impact - these appalling abuses by Done and Cerebral mean we need more calls for thoughtful pause when it comes to working with startups. Particularly about funding's role - my favorite topic! 🤑 How did we end up with venture capital and PE financing in healthcare that risk the safety of kids in the name of exorbitant returns? Not that all VC or PE dollars are bad, of course, but they're certainly key drivers who shouldn't be in that seat. Did we underestimate these funders as 'barbarians at the gate', much like the pharma reps of the 90's and early 2000's heyday? Have we not learned from Purdue Pharma's aggressive and deadly Oxoycontin marketing? Purdue pleaded guilty to criminal charges and paid $600 million in fines in 2007. Or TAP Pharmaceutical Products's Lupron kickback scheme for the prostate cancer drug? TAP also pleaded guilty to criminal charges and paid $875 million in fines in 2001. Or Pfizer marketing Neurontin, an anti-seizure drug, for off-label uses, such as treating pain and bipolar disorder, even though the drug was not approved for these purposes, and paying physicians kickbacks. In 2004, Pfizer pleaded guilty to criminal charges and paid $430 million in fines. Cerebral and Done's playbooks were practically the same thing, just with a modern mid-pandemic, low-regulatory scrutiny, digital-platform twist. Will appropriate regulation ever outpace American venture greed? Is it even possible to ensure patient safety AHEAD of tragedies driven by the intersection of innovation and venture funding? If you're keeping score, healthcare regulatory reactivity: 1 million. Healthcare ounces of smartly preventive policy: 3. Blech. 😖 When will we finally own that prevention in-house? #healthcare #overdoseprevention #suicideprevention

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The Illusion of Efficiency in Healthcare: A Deep Dive into ACA's Impact Remember the argument on the quality and efficiency of healthcare during the ACA debate? This argument led to policy changes in the ACA that facilitated hospitals buying up physician practices and insurance companies owning pharmacies and benefits managers—both industries becoming big in the process. The notion was that by becoming big, both industries could bring in efficiencies by eliminating wasteful expenditures. But what happened? Both industries consolidated their market share and raised prices for the consumer. Hang on, one might argue that while we could not reduce the cost, we have improved the quality, and quality comes with a price. Fair argument, right? Has the quality of care improved? Well, this paper answers that question with a resounding NO. At least in this study, the quality of healthcare—as measured by in-hospital mortality, 30-day mortality, and 30-day readmission rates among a select patient population of a large independent cardiology practice before and after their integration with a large academic health system—did not improve. Another argument used in the ACA debate was that vertical and horizontal integration would reduce the utilization of services such as labs and scans because they would be more easily accessible through electronic health records. Has this argument survived research scrutiny? Again, the answer is NO. This study found no difference in the utilization of services when comparing before and after integration. Funny enough, I asked Google AI, “Does integration of outpatient practices with hospitals improve quality?” The Google AI overview gave me this answer: “Yes, integrating outpatient practices with hospitals generally leads to improved quality of care by facilitating better coordination of patient care, streamlined communication between providers, and access to more comprehensive services across different healthcare settings, ultimately enhancing patient outcomes,” and provided a list of references. All of them were review articles by influencers saying how “it feels good.” None of them referenced how “it felt good.” I hope the L!nk€d!n algo will pass this post in its quality check. What are your thoughts? #Healthcare

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Starting April 1, 2025, Rural Health Clinics (RHCs) can include CPT Category II codes on Medicare claims. This advancement enhances quality reporting and aligns with value-based care initiatives, as these codes offer detailed insights into patient care. Previously, such submissions led to claim rejections; now, they aim to improve reporting accuracy without altering payment policies. Integrating these codes into the revenue cycle offers several benefits: 1. Accelerated Claims Processing: Detailed documentation reduces the need for additional payer audits, leading to quicker payments and less administrative burden. 2. Improved Quality Metrics: Tracking performance in areas like diabetes management aligns with programs such as Medicare’s Quality Payment Program, potentially resulting in higher reimbursements or bonuses. 3. Error Reduction: Precise coding minimizes errors in claims submissions, decreasing rework and payment delays. 4. Enhanced Negotiation Leverage: Demonstrating high-quality care through data enables better terms with private insurers, leading to higher payment rates or inclusion in premium networks. 5. Alignment with Value-Based Care: Participation in value-based contracts, where outcomes and quality metrics drive revenue, can unlock shared savings and incentive payments. While CPT Category II codes themselves are not reimbursable, their strategic use supports faster payments, fewer denials, and operational efficiency, positively impacting cash flow and the revenue cycle. #Medicare2025 #RuralHealthCare #CPTCodes #QualityReporting #HealthcareUpdates #ValueBasedCare #HealthTech #RHCUpdates #MedicalCoding #HealthPolicy #RevenueCycle #HealthcareInnovation #PatientCareQuality #HealthCareReform https://lnkd.in/etXFK3UG

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100% satisfaction in birth metrics! What is the secret? Cleveland Clinic achieved 100% satisfaction across five birth metrics, a notable feat that Becker's Hospital Review highlighted. Cleveland Clinic adopted TeamBirth in October 2022. TeamBirth is a care delivery model jointly created in 2021 by Harvard Pilgrim Health Care, Ariadne Labs and UMass Memorial Health. It emphasizes routine check-ins with all patient care team members and family at key points to streamline communication about birth preferences and patient status, using a whiteboard as a key tool. Since adopting it, the health system saw the rate of C-sections for Black mothers go down from 41% to 22%. Rates also improved for white mothers, dropping from 27% to 23%, bringing the outcomes for its patient populations to a more equitable level. ▶ Satisfaction went up across five categories in 2022 to a perfect 100% for: ➡ Friendliness/courtesy of the unit — up 10% from 2022. ➡ Staff concern, information about progress and baby’s condition — up 12% from 2022. ➡ Nurse promptness in responding to patient call — up 12% from 2022. ➡ Nurse's attitude toward patient requests — up 13% from 2022. ➡ Doctor and staff working together during birth — up 15% from 2022. Patient satisfaction grew by 23% — from 72% in 2022 to 95% in 2024 — for how well they felt Cleveland Clinic managed their pain during labour. Transparent communication is important to promoting safety and reliability in high-risk organizations. ♻ How is the communication in your organization? #healthcare #communication #reliability

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Do you want to see who knows what we need to do and what is most important to fix health care? Listen to Sue Veer addressing this Committee. Hear from those who have a heart for serving most Americans most behind and are willing to sacrifice to address the next generation always ignored - and then we wonder why outcomes get worse. She was discussing 340B in about them most balanced and informative way possible. She noted how the CHC used 340 B "supports health care services that would otherwise be unavailable in many of the communities that we serve... the one that is near and dear to my heart are those early childhood services that are otherwise unfunded because we are building the health of the future generation" - Early Childhood Services - Sue Veer - More than a Hero - A leader for our nation and absolutely on target with her heart and her service and her testimony $600,000 margin lost and 0.6 FTE of labor to comply with 340 B - loss of nearly $700,000 in delivery capacity for those most in need! Did you hear this Congress, CMS, and others how you cut the lifeblood and distract the delivery team members time and time again over the past 40 years of design changes. Stop killing hospitals, practices, and delivery team members where most Americans are most behind. Start paying attention to Sue Veer and many others like her who can teach you how your designs fail and how they can work - for future generations. You do not fun health care where needed. You have forced a patchwork. Please don't kill the patches and pieces before you actually implement a plan for sufficient basic health access for 95% of the nation, not just 50 - 60%. Listen to the heart of health care delivery. Listen to those that you must fully fund who are the only ones that can be most and best for most Americans most behind.

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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

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Building strong physician referrals isn't just about waiting for patients to come to you—it's about actively increasing your visibility and effectively communicating with your peers. Try these steps and see how they help you get more referrals! More of this in my newsletter: https://pxl.to/AD/arbfg5e #drarianademers #Orthobiologics #Physicians

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Reflecting on the implementation of structured, value-based care models: The foundation of effective clinical intervention is a deep understanding of the health system and its key stakeholders. These models must center on the individuals receiving care. Evidence-guided and value-focused care optimizes available resources within health systems, specialty programs, and health services, leading to qualitative and valuable care delivery. The result? Better resource utilization, improved outcomes, and enhanced individual health. This approach is essential for organizations that design true care pathways rather than virtue signaling or creating superficial content. Having been intimately involved in Value-Based Care design and implementation, I'm eager to partner with forward-thinking organizations to continue this vital work. The result - a healthcare system that truly serves its patients and stakeholders - is a goal worth pursuing. If you're passionate about transforming healthcare delivery, let's connect and explore how we can drive meaningful change together. #ValueBasedCare #HealthcareInnovation #ClinicalPathways #HealthcareTransformation #letstalk

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To all doctors and medical professionals. This message is for you. 👇🏼 Are you struggling to connect with your patients? You have to read this book! "What Do Patients Really Want?" is a must-read for all healthcare professionals who want to build stronger relationships, empower their patients and achieve better healthcare outcomes. Do you want to read it or give it to your doctor? Find it here: https://lnkd.in/dDEZpVYf

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A very important infographic highlighting the importance of the #DoctorPatientRelationship and what #patientcentricity needs when considering the #patientvoice and #providervoice 🙏🏼🌹

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EQIP – PC                                              A strange acronym               But a great model for health equity and independent primary care delivery Here is the important information- followed by the more mundane details below: -         An innovative Maryland Advanced Primary Care and Health Equity Funding program -         Infrastructure funding to build new advanced primary care sites in areas that are medically underserved, have high Area Deprivation Indices and high rates of avoidable hospitalizations. -         Intention is to attract and establish new primary care providers, as opposed to shifting around current providers -         Non-visit-based Medicare payments in addition to Medicare Fee for Service payment -         Blending into Medicaid VBP beginning in 2026 -         Strong inclination toward independent entities, as opposed to corporate owned or supported entities -         Focus on health equity, community health workers and behavioral health integration and linkages to community-based services -         Five-year model that progresses to integration into the larger Maryland Primary Care Program -         Free linkages to the state’s Health Information Exchange (CRISP) and AI event prediction advanced health informatics tools At a time when vanishingly small numbers of primary care residency graduates are choosing to establish their own practices, this thoughtful program’s features are ideal to attract young primary care physicians who have always dreamed of moving to an area where they are greatly needed and appreciated. Even better, the startup costs are funded by the state, and they will be given abundant technical support to build a strong modern practice.   Here is how the program fits into the state healthcare delivery system.  The State of Maryland, the Maryland Department of Health, the Health Services Cost review Commission, and the Center for Medicare and Medicaid Innovation released an application for the Episode Quality Improvement Program- Primary Care (EQIP-PC) program. This program was derived from waivers within the state’s overarching Total Cost of Care contract and will be managed by the Program Management Office of the Maryland Primary Care Program, under the capable leadership of the Executive Director Chad Perman. Perhaps the most important message from this collaborative work of the State Health Department, the state HIE (CRISP), Hospital Rate Commission, and CMMI is the intentional creation of a “health delivery system” with solid leadership and broad stakeholder input. If successful this model can be a catalyst to the rebirth of independent primary care practice, the heart of all successful healthcare systems Yours in health Howard

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Anyone else just swallow another healthcare cost increase in choosing benefits this month? This newly released NEJM Catalyst article is timely https://lnkd.in/exWdtwZq. Improving affordability is broadly seen in the U.S. as our #1 healthcare policy issue. Mark McClellan offers great insights here. Ultimately, without inappropriately stifling the juggernaut of tech innovation, we need to be laser focused on achieving the quintuple aim through new processes AND tech (and some appropriate gov regulation) that address this elephant in the room of massive expense. There are few studies that have shown such promise more than the hospital at home care model. Acute care alone constitutes over half of all Medicare costs. The opportunity is real. We at the Hospital at Home Tech Council are working diligently with partners to ensure that we build and enhance current/emerging tech (POC diagnostics, RPM, virtual visits, supply chain, etc) to leverage this opportunity to achieve the quintuple aim. Please join with us! And if you're heading to HLTH Inc. conference next week, ping me to connect on this topic. #patientsfirst #healthcareaffordability #healthcarepolicy #hospitalathome #healthcaretech #futureofheatlhcare #poc #diagnostics #remotepatientmonitoring #supplychain #nejm

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🔩 Q: What is a Bolt on healthcare benefit? ✅ A: Great question! Self-funded ERISA-governed plans may add on OPTIONAL services to provide more options for members and potentially save more time and money for both plans and members. We call these "bolt-on benefits" in the industry. Here are some examples, and even focused examples on #prescriptiondrugs and #pharmacy: 💊 -On site or near site clinics - that can provide quick appointments for members to get in to the doc or provider when their primary care providers are not available. At these clinics, members can obtain many drugs at these on site or near site clinics at a discount or even free to get them started and up to 100% of the drugs could be charged back to the plan. 💊 -Canadian drug importation programs - patients are allowed legally to personally import drugs with several stipulations (not biologicals, not controlled substances). I will reserve my personal opinions on these Canadian programs for now, but just know that they can be another option for members. 💊 -Cash pay on prescriptions and applying the cost to deductibles and OOPs - especially for the 1/3 of plans that are High Deductible Health Plans (HDHPs) - your plan, if you have a savvy consultant or broker, can set up a program to allow those with HDHPs to apply their receipts to their deductibles and out of pocket accumulators at the beginning of the plan year when patients have to pay out of pocket. You MUST ask your broker, however, if they can set up this option for your plan with the medical carrier, and show a clear pathway at open enrollment for members on where they may turn in their receipts to apply to their deductibles. 💉 Example: 1/1/25 is right around the corner and 70% of plans' accumulators will reset. With the Team Cuban Card, for example, people may pay cash of $748+ cash price with Yusimry, an adalimumab biosimilar, (https://lnkd.in/g5gJz_Mf) or they can purchase a more expensive option on their drug formulary. Why not take advantage of better cash pricing and rewarding the member for finding it and applying it to the deductible? 🛑 Now that the breach of fiduciary lawsuits have arrived, considering bolt on benefits is/are another critical component for plans to explore. If you offer your members options, you're demonstrating that one way your plan is meeting their fiduciary obligations. Maybe all these won't work for your plan.....but you miss 100% of the shots you never take. #pharmacybenefits #pharmacy

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What is now known as Medicare Advantage started in 1997 as a way for private companies to oversee Medicare beneficiaries with the idea that the private sector could provide healthcare more economically. Medicare Advantage is a $450-billion-a-year system that covers more than half of the 67 million seniors and disabled Medicare eligible beneficiaries. An investigative report found that many of these private insurance companies, like UnitedHealth and Humana, made hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments from 2018 to 2021. "UnitedHealth members were about 15 times as likely to have that diagnosis as the average patient in traditional Medicare." "Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs." The sicker the patient, the more Centers for Medicare & Medicaid Services pays the the private insurance company to care for the Medicare "DIS"Advantage beneficiary. Did you know that Medicare Advantage programs are allowed to audit doctors' and other providers' medical records to add diagnoses for these patients if they think the doctor "missed" a diagnosis code? Medical practices like mine receive post-payment medical record audits so UnitedHealth Group, Aetna, a CVS Health Company, Florida Blue, Humana, Cigna Healthcare and others can add #diseases and #conditions they believe the patient has. Where is the checks and balance on this? https://lnkd.in/euz9bhqZ

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Thoughts from the Wild Health Summits Burning GP Summit: Should there be a salaried GP model to provide for patients that aren't fit for fee-for-service? Repeatedly throughout the day, there are examples of the current funding models failing complex patients that don't fit into the fee-for-service paradigm. This has been a problem for years, and despite advocacy from lots of different groups, patients with complex health needs continue to be failed by the fee-for-service model. We are in a situation where GPs are subsidizing these patients' care with their own income, and their own families suffer a drop in financial wealth as a direct result of GP altruism. Are we now at the point where we should consider a truly publicly funded, universally accessible, primary care GP-led system? The single employer model could be a soft landing for this idea. In reality small GP clinics are continuing to fail in low socioeconomic areas due to the inability of patients to pay a gap alongside poor Medicare rebates, I'd argue the government should be stepping in to nationalize these clinics when requested by practice owners and GPs. I know there are a lot of younger GPs who would be quite happy to spend part of the week in a salaried role doing altruistic work and spending another part of the week in a different role l/clinic doing private fee-for-service work. Is it time for a discussion about what this looks like? We’ve already seen councils and other funding bodies stepping to rescue small rural clinics. Maybe it’s time for a national approach. Jeremy Knibbs Michelle O'Brien The Royal Australian College of General Practitioners (RACGP) Australian Medical Association

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Rural health. Is the one we’re we need to see improvement not in care, but in operational efficiency. So nice to see implementation of AI methodologies. I have been a bit of a sceptic, AI tool tries to save physican and care provider time, but than they are over burdened with administrative tasks. So glad to see AI Grand Rounds giving a realistic picture of what is happening by in the field and not just hype. If we want real victories, we need to tackle at multiple levels, AI is absolutely a yes these days, but organizations should adapt and want to make provider lives better. AI Grand Rounds Dallas AI #RuralHealth #healthequity

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