Jeff James

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

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The PDP market is something that we at Healthsperien LLC have been closely watching and advocating around. The demo and the $15 premium waiver are laudable adjustments to a marketplace that is facing a perfect storm of financial pressures. However, more work has to be done around other aspects of the Part D program - namely Star Ratings - as applied to particular subsets of the Part D program. Specifically, those benchmark plans with high % of LIS beneficiaries (~20% based on the data we've looked at). Those plans have extreme difficulty satisfying minimum Stars thresholds and while financial amelioration is necessary, it is not sufficient for an all around response to the woes of that particular market subset.

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New study in #HSR from Yevgeniy Feyman PhD et al  measure specialty provider networks in Medicare Advantage (MA) and examine associations with market factors. WHAT IS KNOWN There is limited evidence on the relationship between MA network breadth among specialists and plan or market factors. WHAT THIS STUDY ADDS Using a recently developed algorithm for measuring the restrictiveness of primary care providers, this study measures the network restrictiveness of nine high-prescribing specialties among MA contracts. CONCLUSION Findings suggest that rural beneficiaries may face disproportionately reduced access in these networks and that efforts to improve access should vary by specialty. FULL ARTICLE: https://lnkd.in/gnn6Uwmk Wiley AcademyHealth #HSR 

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Introduction of Medicaid APM options for federally qualified health center (FQHCs) was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. https://ja.ma/4daDw8H

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Are you participating in the #healthIT summer reading program? It includes the following: ✅ Office of the National Coordinator for Health Information Technology (ONC) HTI-2 Proposed Rule ✅ Centers for Medicare & Medicaid Services CY25 Medicare Physician Fee Schedule (MPFS) Proposed Rule ✅ Centers for Medicare & Medicaid Services CY25 Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System Proposed Rule. Happy reading! 📚☀ #interoperability #healthIT #HTI2 #HIE #publichealth

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Sharing key takeaways on the CMS Hospital Inpatient Quality Reporting program for FY2025. - Seven new measures are added (which are welcome, with the caveat of let's see how they work out) -> Patient Safety Structural Measure beginning CY 2025 with payment determination in FY 2027 -> Age Friendly Hospital CY 2025/FY 2027 -> Catheter-Associated Urinary Tract Infection Standardized Infection Ratio Stratified for Oncology Locations (CAUTI- Onc) CY 2026/FY 2028 -> Central Line-Associated Bloodstream Infection Standardized Infection Ratio Stratified for Oncology Locations (CLABSI-Onc) CY 2026/FY 2028 -> Hospital Harm – Falls with Injury (eCQM) CY 2026/FY 2028 -> Hospital Harm – Postoperative Respiratory Failure (eCQM) CY 2026/FY 2028 -> Thirty-day Risk-Standardized Death Rate Among Surgical Inpatients with Complications July 1, 2023–June 30, 2025/ FY 2027 - Five existing measures are removed (which is a breath of fresh air) - the unpopular PSI-04, and measures related to 30-day episode payments for acute myocardial infarction, pneumonia, total hip/ knee arthroplasty, heart failure - Two existing measures are modified (Global malnutrition composite score expanded from seniors over 65 to anyone older than 18 - this is very positive; and Refined HCAHPS measure - will post details on this next week.)

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Today the Centers for Medicare & Medicaid Services (CMS) published the request for applications (RFA) for the ACO Primary Care Flex (PC Flex) Model, which will test #primarycare hybrid payments within MSSP beginning January 1, 2025. (https://lnkd.in/epgeV9ie) The application portal is open now (https://lnkd.in/erZPbmGq). To apply, ACOs must submit an MSSP application (as an initial, re-entering, or renewing/early renewing applicant) and a supplemental PC Flex application questionnaire. The MSSP application is open now through June 17 at 12:00pm (noon) ET. The PC Flex supplemental application must be submitted by August 1, 2024. CMS will host a model applications webinar on June 6 at 2-3:30pm ET. (https://lnkd.in/eVJJKrrP) Considerations for applying to PC Flex were discussed during NAACOS' MSSP 2025 Application Insights webinar yesterday, the slides and recording will be available on-demand shortly (https://lnkd.in/ejizaatZ). Stay tuned for additional NAACOS resources on the PC Flex model. Key model details: > The model will run January 1, 2025 – December 31, 2029. > Eligible participants are low revenue ACOs using prospective assignment that begin a new MSSP agreement starting Jan. 1, 2025; ACOs cannot simultaneously participate in Advance Investment Payments (AIP). > Participation is at the ACO level and all ACO participants and their primary care providers will be required to participate; fee reductions will be applied at the TIN/NPI level. > In addition to the MSSP application and PC Flex questionnaire, applicants must submit a spend plan, roster of non-physician practitioner data, and assurance of ability to repay; applicants may withdraw the PC Flex application at any time prior to signing the Participation Agreement (December 6 – 12, 2024), and may withdraw the PC Flex application without impacting the MSSP application. > Participants will be required to submit a health equity plan, collect and report health equity data, and secure a repayment mechanism (separate from MSSP repayment mechanism for 2-sided tracks). > ACOs will distribute the Prospective Primary Care Payment (PPCP) to their participant primary care providers, FQHCs and RHCs. CMS will require ACOs to publicly report information on the distribution of the PPCP. #valuebasedcare #accountablecare #healthcareinnovation

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AI’s Impact on CDI A recent ACDIS Survey of ACDIS members gauging impact of AI on CDI processes and the CDI profession revealed some interesting points and sentiments towards AI. The most common impacts from the implementation of CDI technology are increases in remote work and in productivity (cited by 67% each), followed by identifying “low-hanging fruit” queries (65%) and improving documentation issues with high-volume DRG groups (54%). Additional responses appear in Table 4 below. Remote work is not conducive to effectively providing sustainable measurable physician documentation educational training. One-on-One training or small group training is most effective in ultimately changing overall physician behavioral patterns of documentation. Often, the best form of training is small bit size nuggets provided in a quick conversation specific to a case on the floor. Productivity is not a valid and reliable measure of CDI performance. The mere fact that the CDIS reviewed a record does not necessarily equate to achieved improvement/integrity of the record. Identifying low hanging fruit diagnoses through queries implies CDI has room for improvement in physician documentation education through reinforcement that improves physician's muscle memory of better documentation practices. Electronic querying serves to mechanize the query process and is no substitute for physician documentation training and knowledge sharing. Physicians do not want more queries, they prefer to document right the first time versus more repetitive transactional reactive queries. AI definitely can assist and serve as an effective tool in CDI activity. However, it must be considered as a tool and not a crutch. There simply is no substitute for good old fashioned CDI boots on the ground, helping physicians achieve clinical documentation excellence through documentation training with reinforcement and guidance. AI is the panacea for improving documentation. #AI, #documentationimprovment, #notapanacea

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If you build it, will they come? I’ve heard countless organizations - #MA plans, #Medicaid plans, risk-bearing providers, vendors, PBMs, and retail players - say “we need to build the capabilities to XX”. Many are looking to vendors for solutions, but few vendors are ready to invest in new capabilities without contracts.  Anyone else sensing this (problematic) new conundrum? Here’s my quick take and a few ideas to break through this barrier. Many sales meetings are often held with functional departments, and often do not include the #MedicareAdvantage #StarRatings, #RiskAdjustment, #HEDIS, IT or P&L owners. We must collaborate to get those departments’ urgent needs integrated into new vendor purchases in order for new activities to meet new and emerging needs, remembering that: 🌟 Vendors are vital to your success.  🌟 Vendors operate in a more volatile environment than plans. 🌟 Vendors have smaller budgets than plans. 🌟 Vendors need signed contracts to make significant investments.   🌟 Vague RFPs waste vendors’ time and resources. Collaboration creates win-win contracts which expand capabilities of both parties. I encourage plans to: ✅ Ask vendors about their roadmap; including timing and certainty of planned enhancements. ✅ Include the #Stars, Risk Adjustment and #PartD teams in new vendor discussions. ✅ Consider adding a vendor's roadmap capabilities to contracts. ✅ Co-create with trustworthy vendors. I encourage vendors to: ✔ Ask about the customer’s unmet needs. ✔ Offer to co-create solutions to new and emerging needs with willing customers. ✔ Offer to accelerate roadmap capabilities with willing customers.   ✔ Articulate the things you would be willing to do if a customer would be willing to contract for it. This is a #MarketMakingMoment as #CMS has thrown down the gauntlet with #NewNeedsOfStars and #NewNeedsOfMA. This is a stellar time for vendors to review current and planned capabilities with a broader lens on new and emerging MA, #Compliance, Stars, #ECDS, #Interoperability, #HealthEquity, Medicaid & #SNP Aligment, and Risk Adjustment needs. If you need help, reach out to us.  #WhatGotYouHereWontGetYouThere  ⭐ ⭐ ⭐ ⭐ ⭐

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HHS recently published a report highlighting the department's programs, activities, and policies to address social determinants of health. The report documents the progress that has been made towards achieving the three goals of their SDOH strategy: enhancing data infrastructure, improving connections between health and social service providers, and engaging in whole-of-government collaborations to implement comprehensive solutions. Read the report to learn more about HHS agency activities to address social determinants of health:

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Key Strategic Insights = A Successful OP CDI Program The challenge of value-based care starts with a collaborative approach, when launching an Outpatient Clinical Documentation Integrity (OP CDI) program. Here are some key strategic insights to success: 1. Engage with Population Health Understand Pain Points: Begin by understanding the specific challenges faced. This fosters collaboration. Tailored Questions: Use customized questions to facilitate productive discussions and ensure alignment with needs. 2. Effective Software Implementation Manage Patient (Pt.) Volumes: Implement software solutions to efficiently handle pt. volumes. OP CDI Calculator: Utilize a calculator to determine Full-Time Equivalent (FTE) needs. Data Analytics and Reporting: Emphasize the importance of continuous improvement via data analytics. 3. Workflow Creation Establish Robust Workflows: Create strong workflows before integrating reviewers. 4. Collaboration & Communication Promote Strong Collaboration: Encourage robust communication between key stakeholders. Leverage Software: Use technology to reduce physician burnout & streamline communication. 5. Patient-Centered Approach Address social determinants of health (SDOH) & ensure accurate documentation of conditions and care plans. Patient Outcomes: Keep patient care at the center of all doc. & workflow processes. 6. Regulatory Compliance Adhere to Guidelines: Follow regulatory requirements such as CMS guidelines on Hierarchical Condition Categories (HCC) coding to avoid penalties and enhance credibility. 7. Measurable Outcomes Set Clear Goals: Aim for measurable outcomes like improved HCC recapture rates, enhanced RAF scores, better HEDIS measures, and addressing SDOH needs. 8. Stakeholder Engagement Involve All Stakeholders: Ensure that executives, clinicians, and other relevant parties are involved in planning and implementation process. Success Stories Recently, I helped several CDI directors validate their cases for OP CDI programs within Accountable Care Organizations (ACOs). By engaging with population health leadership, we identified key issues such as RAF gaps and HEDIS measures, and tailored processes to address them. For instance, a CDI director I guided successfully identified HCC and HEDIS recapture as their biggest pain points. With strategic solutions in place, they are now ready to implement the project for the 2025 budget yr., aiming to improve their HCC recapture rate by 20%, leveraging data analytics for outcomes and improvement needs. Benefits of Implementing These Strategies Align Risk Stratification: Properly align risk stratification with chronic conditions and healthcare needs. Quality Measures: Improve quality measures and address SDOH. Collaborative Team: Ensure success with a collaborative team supported by technology. Overall, these strategic actions will enhance patient care and operational efficiency. #Healthcare #Leadership #CDI #PatientCare #ValueBasedCare #HealthcareInnovation

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Humana has revised its Medicare Advantage policy, withdrawing its categorical stance against coverage for peripheral nerve stimulators (PNS). IPSIS continues to monitor this issue and invites you to share your Humana PNS payment experiences on the IPSIS Open Forum. https://lnkd.in/gEkY7CMF #IPSISAdvocacy #neuromodulation #InterventionalPainMedicine #PainMedicine #Interventional-PainManagement #PainManagement

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Full Medicaid expansion needed to retain Georgia’s physicians Georgia was ranked 5th worst place to practice in a recent Medscape article (“Best and Worst Places to Practice 2024”), using five criteria: physician compensation, cost of living, malpractice premiums, the health of the state’s residents, and physician burnout levels. As current and future physicians and health advocates, this column will add context by detailing our experiences practicing in Georgia. It is no surprise that three of the five worst-ranked states for practicing are among those that have not expanded Medicaid. In Georgia, refusal to expand Medicaid means that nearly 12 percent of residents (well over a million people) are uninsured, significantly limiting their access to healthcare. Only in Texas is coverage worse. Due solely to political concerns, Georgia chose to submit a Medicaid waiver and develop its own Medicaid expansion program, Pathways to Coverage. The governor’s office projected that the program would cover an additional 100,000 Georgians in its first year. But it has been an utter failure, with fewer than 3,500 covered at a cost to taxpayers of $26 million. Full Medicaid expansion would have added over 350,000 Georgians while cutting state spending by $710 million. These three states that refused to expand Medicaid are not surprisingly red. It is also unsurprising that the states with the greatest percentage of unhealthy residents are red. Hopefully, Georgia who thought they had a better way of expanding access to care with their own plan that squandered $26 million to cover 3,500 residents will realize that retaining physicians requires a more sensible approach to expanding access to care. #expandinghealthacess, #accesstocare, #limitingcoveragetoresidents https://lnkd.in/eefqH-9Y

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News from First Report Managed Care Volume 21, Issue 2: The Centers for Medicare & Medicaid Services (CMS)'s AHEAD model aims to improve population health management by awarding funding to states and promoting primary care investment and enhanced equity measures, but implementation challenges and cultural shifts may hinder its success. “States have relationships with many of the stakeholders whose perspectives and support will be vital to the success of this model,” Maureen Hennessey, PhD, SVP, director of value transformation at Precision AQ, told First Report Managed Care. Access the full issue here: https://lnkd.in/eKAWrpWp #FirstReportManagedCare #FRMC #CMS #AHEADModel #PopulationHealth

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I’m thankful that I could share my thoughts at that very hearing. There is so much misinformation about 340B. For me, it comes down to two main points: 1- if hospitals need that money as a subsidy to fund everyday activities, they should just ask for a subsidy. Let’s open up the books of these institutions, which already get a huge subsidy with their non-profit status, and see why they are running in the red. Are they really losing money on Medicaid patients or are they just bloated and inefficient? 2- let the subsidy follow the patient. This is a drug benefit program. Why does the funding go to an institution? Imagine if we did that with SNAP, giving a bunch of money to large restaurant chains in exchange for their promise to use the revenue to provide food for poor people (with no oversight to ensure that’s done). We don’t do that; instead we give the benefit to the person who needs it. Let’s change 340B to match that model. Adam J. Bruggeman, MD, MHA, FAAOS, FAOA Daniel Choi Colin Yokanovich John Strom Peter Stein Adam Fein Deborah Williams Lisa Grabert Maya Babu, MD, MBA Katie Orrico Larry Bucshon, M.D. Ann M. Richardson, MBA

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