Kate Goodrich

Most viewed in the last 7 days from JAMA Health Forum: This JAMA Forum discusses the current data collection mechanisms used for Medicare and proposes ways to improve nationwide data collection efforts for Medicaid. https://ja.ma/4dJuqzJ

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A new #EBHC scoping review explores how health service and delivery systems in high-income countries define and operationalise #HealthEquity. 👉 https://ow.ly/ZxaY50ShGWU

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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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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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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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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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The Political Risk Vector: Money, Influence, and Ideology in Healthcare Policy Part 1 The political risk vector in healthcare's three-body problem merits closer examination, particularly regarding the outsized influence of money and special interests in shaping policy outcomes. While financial risk management and patient risk mitigation operate within relatively defined parameters, political risk is uniquely susceptible to external pressures that can distort evidence-based policymaking. Industry lobbying represents a powerful force in healthcare politics. Professional organizations, pharmaceutical companies, insurance providers, and healthcare systems collectively spend billions annually to influence policy decisions. These entities often frame their positions in terms of patient benefit or system efficiency, but their primary motivation frequently aligns with preserving or expanding market share and profit margins. This creates a fundamental tension between evidence-based healthcare delivery and profit-driven policy outcomes. The role of science denial in healthcare policy presents another critical dimension. Despite robust evidence supporting certain healthcare interventions or delivery models, ideologically-motivated opposition can impede implementation of evidence-based policies. This science skepticism often intertwines with political identity, creating barriers to reform that transcend purely technical or economic considerations. The COVID-19 pandemic starkly illustrated how political ideology can override scientific consensus, with devastating public health consequences. Campaign finance further complicates the political risk landscape. The unfettered flow of money into political campaigns creates implicit and explicit obligations that can supersede both scientific evidence and patient needs. Politicians must constantly balance constituent interests against donor priorities, often leading to policy compromises that prioritize political sustainability over optimal healthcare outcomes. This dynamic helps explain why policies with broad public support but industry opposition often fail to advance.

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A brief thread on how MLR is often a stat that is juked (h/t to The Wire) in the “value-based” care world. The medical loss ratio (MLR) is a financial metric used in health insurance and managed health care to measure how much of a premium dollar an insurer uses to pay medical claims and quality improvement activities. The MLR is also known as the medical care ratio, medical cost ratio, or medical benefit ratio (cite: Healthcare.Gov). Many so-called value-based care models cite their impact in the form of medical loss ratio improvement. Most innocently assume that such improvement is generated by better medical management (I did when I first started working in the field). While this may be the case in some models—it is importantly to note that another way to improve a medical loss ratio is be increasing revenue capture in the form of coding. Said another way, to improve MLR, one can reduce the numerator or increase the denominator. Therefore, when someone cites a major medical loss ratio improvement—the key question to ask is: did the MLR improve because of true medical utilization reduction or because of better revenue capture? Most will glibly (and sometimes dishonestly) say “both.” At which point it’s important to ask, what fraction of Medical Loss Ratio improvement arose from better medical management and what fraction from better revenue capture. Usually, what we will find is that most dramatic improvements in MLR are a function of improvements in revenue capture—and only marginal improvements in medical cost-management. In that way, the so-called “value” produced by many value-based care models isn’t true value. It’s better revenue capture. And many “value-based” care models have been granted undue recognition for medical cost management—citing filthy MLR improvements—that are associated with minimal true improvement in medical expense. This kind of short-cut taking sets back the whole value-based care movement which (while appropriate revenue capture is necessary) should be about overall better cost management and reducing total cost of care—not better revenue capture alone.

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Great commentary and details to be considered from post by Deborah Williams Too few probably understand what you've posted, the other major part of the problem. Commercial insured populations (employers & employees) pay the price for government policy failures that represent major hits on company bottom lines or lead to more individual bankruptcies today. #employeebenefits #employers #commerialinsurance #epcouncil.org

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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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Interesting and thought provoking editorial in this week's edition of JAMA detailing the problems with the current RBRVS system. https://lnkd.in/gKaiXQmz Although I applaud the authors and agree with their assessments, I disargree with the recommendations. We should not waste the time, expertise and expenses necessary to revise an archaic system created 30 years ago in a different environment. Better to freeze the current RBRVS system and build a new value based care system upon it. We need to make FFS less desirable and APMs more appealing if we are going to succeed in moving all beneficiaries into alternative payment models by 2030.

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Centers for Medicare & Medicaid Services releases draft guidance for the second cycle of Medicare Drug Price Negotiation Program, aiming to lower drug costs and improve access for Medicare beneficiaries through price negotiations. Read at The Evidence Base® #heor #healtheconomics #marketaccess #pharma #biopharma #hta #healthtechnologyassessment #healthdata #healthequity #healthpolicy #inflationreductionact #drugpricing

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What’s next for Medicare physician payments? Dr. Andrea Brault breaks it down with Tech Target and explores the implications for #EmergencyMedicine https://lnkd.in/g_jtiErW

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Loper and #Medicare #Reimbursement: What Does the Future Hold? Ganny A Belloni from Bloomberg News wades in (in a terrific article) on the implications of #Chevron and the rise of #Loper on Medicare reimbursement issues. I'm quoted. My take? I think, as I say in the article, Loper will have less impact than people think. Loper eliminates Chevron “deference” by a court to an agency’s interpretation of a federal statute, where that law is “ambiguous”, meaning it can reasonably be read in different ways. Congress can (and will) significantly reduce the risk of litigation challenges in a Looer world by, as Ganny summarizes the point, defining statutory terms more precisely and "more clearly and explicitly giv[ing] the agency the discretion to decide issues". Further, many potential challenges can be avoided by CMS, as I say in the article, by framing "more ... [agency] decisions as ‘factual determinations’ or ‘adjudicative’ questions, where it still is entitled to deference, even after Loper.” To those of you who are fans of the administrative state, take heart. The sky, truth be told, is not falling. #healthcare Centers for Medicare & Medicaid ServicesU.S. Department of Health and Human Services (HHS) #CMS #HHS #APA #administrativestate #agencydiscretion #rulemaking #agencies #administrativelaw

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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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Shifting the financial model alone is not sufficient for the transition - the care delivery, workforce, and many other pieces of the ecosystem with which PCPs interact also need to adjust accordingly. Funding to allow for the startup costs of transformation must be made available. A comprehensive analysis from The Commonwealth Fund: To encourage participation, practitioners say upfront payments, investment in the primary care workforce, and less emphasis on simplistic quality measures are needed, as well as more support for practices to provide accessible, comprehensive care. #primarycare #integratedcare #teambasedcare #healthcare #healthcareonlinkedin

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