Sean Lilley

New blog post by David Hewitt, "Top 6 Reasons Hospitals Must Focus On Uncovering The Dark Data In The Cost Cycle." Boost financial performance, decision-making, and patient outcomes by prioritizing dark data in 2024. #spendmend #healthcareData #darkdata #hospitals

17

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

40

13 Comments

Cost analysis in isolation lacks depth. Consider comparing costs - or cash shortfalls - from multiple angles: -Procedure codes -CPT codes -Payers -Aged A/R A record of CARCs and RARCs can be used to map shortfalls and denials, getting you closer to the root causes. This is what my team calls an RCM Health Check and I’m covering the concept in a webinar this Thursday. Join me here: https://lnkd.in/epuhRSn7 

22

NEWS ALERT- CMS has finally released the 2023 MSSP results. The results provide tremendous insight on the ACO landscape, risk adjustment, and value based care. Here are some numbers: Thanks for reading. Help us get the word out by smashing the like button, sharing the post, or commenting. Key stats -453 ACOs with data released -69% of ACOs achieved shared savings -$3.08 billion dollars in shared savings payments to organizations -The top 10 organizations with the most savings racked up $631M, or 20% of all savings. -Average risk score for the top 10 organizations with the largest savings in pure dollars (not adjusted for ACO size) was 1.137 -Average risk score for the top 10 organizations with the largest savings per beneficiary was 1.379 -75% of organizations with a risk score above 1.00 had shared savings. Only 65% of organizations with a risk score below 1.00 had shared savings. -78% of the largest 100 ACOs by size had savings while only 64% of the 100 smallest ACOs had savings. CMS noted "ACOs led by primary care clinicians had significantly higher net per capita savings than ACOs with a smaller proportion of primary care clinicians. These results continue to underscore how important primary care is to the success of the Shared Savings Program." This makes sense because primary care is such a critical driver in overall patient care success and in accurately reflecting risk scores. There is a LOT more to dig into. My main takeaways are: 1) Primary care participation is a driver of success 2) Risk scores are a critical component of success and organizations in risk should have outpatient CDI programs and strong compliance programs 3) Larger organizations may have more resources and infrastructure to build scale for success Let's talk more about this. What do you see in the data? What is your experience with your ACO? https://lnkd.in/erjc-peV

111

14 Comments

It’s great to see that we covered more US citizens but the overall financial trend is obviously unsustainable. We’ve got to figure out ways to bend this cost curve to something that works over the long haul.

5

From modernizing codesets and #USCDI v4, to ePrior Auth and bulk #FHIR data, the #HTI-2 rule builds on #ONC’s prior efforts to improve processes across #payer, #provider, #publichealth, and more. While the use cases are wide ranging, the entire industry benefits from improved #quality and access to #healthdata. Great news for Tenasol, as we process #clinicaldata of all shapes and sizes, so we are excited to see ONC’s continued efforts to raise the bar for #healthIT and #interoperability.

8

Value-based care (VBC) is reshaping healthcare by emphasizing outcomes and cost efficiency over volume. Originating from managed care models in the 1980s, VBC has evolved with a strong focus on refining payment models, enhancing care coordination, and improving patient outcomes. Key players, including clinical data registries, ACOs, and payers, are crucial to this transformation. By collaborating, sharing data, and aligning incentives, these stakeholders drive advancements in care quality and efficiency. Learn more about how these collaborations can enhance VBC in this Health IT Answers article. https://lnkd.in/gxSPZAgM

8

1 Comment

Eye Opening! As noted by Matthew Holt below, Doximity promotes itself as “The Professional Medical Network for Physicians” with a mission to “help clinicians be more productive so they can provide better care for their patients.” Sounds simple enough, a community built for doctors—a space where they can connect, share insights, and access tools to support their work. Their main source of revenue, subscriptions. Of course, you'd think the subscribers would be the doctors using this valuable platform and its tools, like video calls, hiring services, and various apps, platforms. But look a little deeper at their financials? Yuck. Doximity’s revenue doesn’t come from clinicians at all. The“subscriptions” (main source of revenue) are actually sold to pharmaceutical and other industry players that want access to docs and the powerful (and profitable) prescription pads they wield. These “Marketing Solutions” subscriptions allow advertisers to push tailored content directly into doctors' "news" feeds, with pricing set according to the type and number of doctors targeted. In effect, the platform sells access to doctors to those looking to drive up utilization of their products. Doximity’s real revenue engine (which is pretty amazing, see post below) lies in its advertisers. Life sciences companies and the highest bidders pay for the privilege of influencing what doctors see in their feeds—not just ads, but entire modules and news updates. What seems like a physician’s trusted source of industry news and updates is, in reality, a curated stream designed to serve business interests. This brings us to the key question: when doctors use Doximity as their “news feed” and source of the latest research, are we comfortable knowing their information stream is largely influenced by advertising dollars? When we scroll through platforms like Instagram or Facebook, we’re well aware of how advertising shapes our experience. Mention a skincare product in a text, and suddenly, your feed is filled with face cream ads. We know this, we accept it, and we view each ad with a healthy dose of skepticism. But are we okay with doctors facing the same experience? Are we comfortable with Doximity’s advertisers shaping the content doctors see, especially when they rely on this platform for up-to-date clinical research and product information? Let's hope our docs approach these tools with the same skepticism I do when I'm promised younger looking skin:). Jessica DaMassaPreston AlexanderDutch RojasPatient Rights Advocate Marilyn BartlettDave Chase, Health Rosetta-discovering archaeologistAnn LewandowskiJeffrey HoganDavid Contorno Stacey RichterLee Lewis Shawn GremmingerAndré WENCKER Renzo Luzzatti

29

10 Comments

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

7

4 Comments

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

The Centers for Medicare & Medicaid Services (CMS) has proposed a rule to make Medicare Advantage (MA) plans' prior authorization rules and coverage criteria publicly accessible. This move aims to reduce inappropriate denials, improve patient access to care, and increase appeal opportunities. Currently, only 4% of denied claims are appealed, yet 80% of appealed denials are overturned. The proposal would require plans to publicly clarify coverage criteria and inform enrollees about their appeal rights. Additionally, CMS seeks to enhance Medicare Advantage provider directories by integrating them into Medicare Plan Finder, simplifying provider comparisons across plans. This would empower seniors to make better-informed healthcare decisions. The rule has garnered support, including from Sen. Ron Wyden, who praised its potential to address prior authorization misuse, eliminate "ghost networks," and curb broker exploitation. Public comments are open until January 27, 2025, after which its future depends on policy decisions by the next administration. Our home health and hospice clients will benefit from enhanced transparency in Medicare Advantage rules, ensuring timely access to care and reducing authorization-related delays. Clearer appeal rights and streamlined provider directories empower clients to secure appropriate reimbursements, optimize workflows, and focus on delivering quality care without administrative burdens. Cliniqon is committed to delivering Guaranteed Quality, Ensured Compliance, and Unparalleled Outcomes in Home Health and Hospice agencies. #HomeHealthServices #HospiceCare #FrontEndServices #BackOfficeSolutions #HealthcareManagement #RevenueCycleManagement #HealthcareCompliance #PatientSupport #CareCoordination #MedicalBilling #ClaimsManagement #PatientEngagement #HealthcareOutsourcing #MedicalCoding #ProviderSupport #CliniqonCare #HealthcareSolutions #PatientCareExcellence #HomeHealthRCM #HospiceBilling MedPage Today

5

New Blog Alert! ASTP’s FHIR Action Plan is more than just a policy update—it's a critical guidepost for the health IT industry, helping us understand the direction federal agencies are taking to advance healthcare interoperability. In our latest blog, Kendra Obrist breaks down the key elements of this action plan and explains how FHIR will continue to shape the future of health data exchange. From standards development to innovation and nationwide adoption, this plan sets the course for FHIR’s role in transforming how healthcare data is shared. Stay informed on the latest policy developments and learn how POCP can help your organization navigate this evolving landscape. Read more here: https://hubs.li/Q02SZGHh0 #HealthIT #FHIR #Interoperability #HealthcareInnovation #POCP #PolicyUpdates

2

In a recent article on Digital Health Insights, author Jennifer Bresnick discusses how CMS is lighting a fire under payers to compete on value with 1upHealth's CSO Donald Rucker. Topics include the power of modern data standards (i.e., FHIR) and CMS-mandated APIs to provide transparency around outcomes and cost (i.e., value). 🔥 Don says in part, “FHIR creates the ability to bring financial and clinical data together in a meaningful way so that we can finally draw back the veil on why we spend the most but have some of the worst outcomes in the world. We can begin to codify and compute our definitions of value – and start to compete on that value. You can choose to be threatened by that, or you can choose to make it work for you. The organizations that are going to survive are the ones that pick the latter.” 📰 Read the full article to learn more.  https://lnkd.in/eaYdEqBr #fhir #cmsapis #value

15

What Hospitals Need to Know About Medicare Advantage Challenges... Financial pressures are rising as CMS implements the updated Version 28 Hierarchical Condition Category (HCC) model, which introduces changes aimed at limiting types of codes that are most used for up-coding or over-coding to help rein in spending. The changes will also enhance the accuracy of coding and predictive analytics for patient conditions. Key changes include: ✅ Fewer ICD-10 codes qualifying for HCC mapping ✅ Newly added HCCs targeting specific conditions, removing redundancies ✅ Adjusted groupings to better reflect actual patient risk These updates are expected to lower Medicare Advantage (MA) risk scores, saving billions for the Medicare trust fund. However, they also bring significant financial headwinds, with some health systems anticipating up to 20% revenue reductions, according to Jacqueline Kimmell. Additional regulatory shifts, such as updates to Star Ratings, RADV audits, and prior authorization requirements, further complicate the landscape. 👉 CMS spent $12.8 billion on Star Ratings bonuses in 2023—a 30% increase year-over-year. Achieving high ratings is about to get tougher. 👉 The cumulative impact of these policies could tighten MA profit margins and increase costs related to the Medicare Two Midnight Rule changes. What Should Hospitals Do? Hospitals must take a proactive approach to their Medicare Advantage strategies. ➡️ Renegotiating contracts or adding addenda ➡️ Selecting preferred plan partners ➡️ Streamlining prior authorization and denial processes with payers ➡️ Taking on risk directly to bypass payers altogether Maintaining the status quo isn’t enough. It’s time for health systems to evaluate whether current MA contracts align with long-term goals. #MedicareAdvantage #HealthcareFinance #ValueBasedCare #MAStarRatings #MATwoMidnightRule

14

1 Comment

📊 When was the last time you optimized your EHR? If it’s been 3–5 years, it’s time to take a closer look. We help healthcare organizations maximize the value of their EHR investments with tailored optimization strategies and Epic Refuel projects. 🚦Signs you need optimization: 🔹 High clinician dissatisfaction 🔹 Workflows that don’t match organizational needs 🔹 Frequent help desk tickets Our seasoned consultants ensure your system supports your team—not the other way around. Ready to unlock the full potential of your EHR? #EHROptimization #EpicRefuel #HealthcareEfficiency #PatientCare

2

Interoperability standards continue to shape the #healthcare industry from #CMS regulations to #HEDIS reporting. To set themselves up for continued success, payers must anticipate the coming shifts, and stay ahead of the ever-evolving landscape. 💭 A recent byline in DOTmed.com, Inc from our client Cotiviti dives into the necessary steps payers must take to ensure these standards are met for seamless #dataexchange: https://lnkd.in/ghGB_txj #interoperability #datasharing #FHIR 

6