Mac Davis

Fundamentally true. Healthcare analytics remains a black box or DYI endeavor for most organizations. Wellstack presents an industry first alternative, full stack, comprehensive solution for data aggregation, integration, and enterprise wide, high impact analytics outside of the EHR and any other transactional applications.

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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

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More interesting #news today on #carecoordination and transitions of care, this time specific to bundled payments for hospitals and the #TEAM model. #CMS #Healthcare #reimbursement

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What is the bottom line if you have financial responsibility for a provider group? Your competitors have the ability to know your contracted rates for everything you do. That's the bad news. The good news is that you can know theirs to help you in your next negotiation.

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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

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The 'payvider' becoming a healthcare delivery niche player. It appears all outpatient...infusion, pharma, home health, urgent care, etc. Seeing more signs of consumers being directed by payers. No real, big box hospital purchases. Are beds being isolated and commoditized? #hospitals #healthcare #business #payers

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In win for #healthinsurers and #members, CMS will recalculate 2024 Medicare Advantage star ratings. After recent wins in court, Federal judges told Medicare to recalculate star ratings for SCAN’s plans and one Elevance plan. The new CMS guidance would recalculate quality ratings industrywide, likely increasing bonus payments for many insurers. As health insurers assessed poor financial performance and lower star ratings, member benefits were in the crosshairs. While this won't save all those extra benefits members have come to enjoy, they will hopefully save some of the most critical. Want to learn more about the latest trends in #MedicareAdvantage? Forrester clients can check out our published and upcoming research, including a data deep dive on individuals aging into and enrolled in #Medicare and Medicare Advantage (link in comments). #starratings #qualityratings #CMS #healthcare #memberexperience

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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.

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My takeaways from the Reuters Events Healthcare #digitalhealth24 in San Diego this week. Please pardon any discrepancies 😀 or confusion this morning - Alaska Airlines delayed me for four hours so I could re-live my college days and get to bed at 1:50 am. Here are some highlights: - AI has a lot of potential in health systems, but ethical concerns and risks are top of mind and being wrestled with daily. - Change management is the biggest challenge, not the technology itself. - Tech leaders understand the importance of focusing on problems rather than solutions. Will this mindset spread throughout the industry? - Endeavor Health is a great example of a smart health system with a clear progression from research to enterprise-wide execution. Thanks Justin R. Brueck - The role and definition of the consumer in healthcare is still a topic of debate, especially when it comes to healthcare and services they would rather not spend time or money receiving. No one identifies as a patient! #digitalhealth #healthcare #AI #healthsystems #consumerhealth #healthcareinnovation #changemanagement HCT Consulting Group

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What does the future hold for retail medicine and virtual care? Walmart is the latest to announce their health center closure. https://lnkd.in/geZpMTkS. This following Optum news, VillageMD closing in Nevada, Teladoc Health problems, etc. What comes next? This is another in a long line of examples that technology and even consumer willingness are not enough when the reimbursement environment does not support particular care models. Are we getting ready to lose all the lessons painfully learned during the pandemic? Or will new virtual care models emerge following this round of closures?

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OIG ALERT: Diagnoses reported only on enrollees’ HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023. Before we dive in here I want to say that I have seen HRAs used appropriately and inappropriately during my time in this space. There can be great value for patients, particularly those with limited access to care and or those reluctant to visit their primary care provider. However there is tremendous risk to the system if these visits are a fragmented approach to care and or not aligned with care planning. What the OIG has identified represents the risks and shows care continuity breakdowns. Ultimately organizations and payers must know their vendor partners because there are some really good ones in this space. Earlier this week the OIG released a really interesting look into Health Risk Assessment, or HRAs. These HRAs are often performed in the home by payers or vendor partners. These should be in depth reviews of the patient and include a host of assessments that often are hard to complete in a condensed visit to a provider office. What the OIG found was that 7.5B or about 2% of all Medicare revenue was tied to conditions captured only during these visits. Is that bad? I don’t know. If these are new conditions and then ultimately incorporated into a broader care plan that improves outcomes then they are a great thing. If they are captured, never shared with the care team, and ultimately used to solely drive revenue with little focus on outcomes then it is bad. I suspect there is a mix of both. If I was at the OIG I would want to take a multi-year look at what was captured year over year only in a HRA as a next step. The report recommends CMS take the following actions. CMS subsequently agreed with recommendation number three but not numbers one and two. 1) Impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments. 2) Conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews. 3) Determine whether select health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies. I am doing some advanced analytics on information in the report for future posts but this is a nice easy read for folks. https://lnkd.in/ehNzzSWu

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Medicare Advantage industry update: -Given environmental pressures participating payers are seeking a 2025 reset to reach ~3% margin range -This will need to be done by addressing price vs benefit balance, utilization management, STARS ratings, and admin cost reductions -Risk baring providers and hospital systems are also effected by industry headwinds in terms of decreasing payments and increasing payment denials -MA remains a long-term profitable business due to the increasing demand by patients and enrollee growth... Anyone else dorky enough to be excited to see what AEP and 2025 brings? https://lnkd.in/efyYAQXw

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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

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As a digital health executive (and a consumer of healthcare) I've been reflecting on the significant rise in average U.S. family health insurance premiums over the years: 2000: $6k 2003: $9k 2006: $11k 2009: $13k 2012: $16k 2015: $18k 2018: $20k 2021: $22k 2024: $26k (projected) This marks a staggering 342% increase since 2000, averaging 6.1% per year, compared to the U.S. CPI inflation rate of 2.5% per year. When electronic health records (EHRs) were introduced, many of us (myself included) were optimistic about their potential to reduce costs. The ability to share lab results electronically, alert for drug interactions, and improve coordination of care seemed like a promising path toward lower healthcare expenditures. However, the anticipated outcomes haven't materialized as expected. As we now look toward AI for solutions, I find myself questioning whether it will truly address these escalating costs. Several factors may contribute to this issue: - The rising rates of obesity since 2000 has tripled. - An aging population with longer lifespans - Provider shortages and increasing burnout - Challenges with interoperability - Market dynamics and regulatory environments - Instances of fraud and abuse I'm interested to hear your thoughts: What do you believe are the primary drivers behind the rising costs. Did EHRs fail us? Can AI fix this?

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Looking forward to sharing recent KLAS Research insights at the upcoming The Millennium Alliance Assembly and learning from attendees their expectations in #digitalhealth for 2025. 🔎 What are the investment priorities of 100 healthcare provider executives and 50 payer executives over the next 2 years? 🔎 How do provider priorities compare to patient expectations? 🔎 What are the current digital health problems that you are trying to solve? 🔎 What digital tools do you plan to add, consolidate, or eliminate? 📢 CHALLENGE FOR THE LINKEDIN COMMUNITY Using 5 words 'What digital health trends do you expect to see in 2025? ' Fun fact: we are about to be 40 years since Marty McFly got in the DeLorean.

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A big thank you to William Fleming, PharmD, Stacey Finster, Chris Caudill, Fabio Baglioni, Lorena Neibaur, and Jay Finster for the incredible opportunity to collaborate on such a transformative vision for healthcare. Together, we’re tackling some of the biggest challenges facing patients and providers, with Healthyr leading the charge to simplify and enhance the care experience. The healthcare system often feels fragmented, making it hard for patients to connect with providers and access the care they need seamlessly. Healthyr is addressing this with interoperability, connecting EMRs, wearables, and self-reported data, so critical information flows smoothly. The future of healthcare isn’t only about advanced technology; it’s about making compassionate, seamless experiences the norm. We’re making this happen at Healthyr, one innovative step at a time, with a commitment to personalized care, patient-centered insights, and improved health outcomes. We’re shaping a future where healthcare is simplified and personalized.

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As 2024 concludes, healthcare leaders have gained critical insights amidst rapid advancements and challenges. Here's a glimpse of the year's key lessons: 🔍 Data as a Strategic Ally: Harnessing real-time analytics transforms operations and patient care. 💻 Telehealth’s New Era: Virtual care isn't just an option—it's expected. 🩺 Workforce Resilience: Supporting staff well-being is pivotal for quality care. 💡 Personalized Patient-Centered Care: Building trust through tailored approaches ensures loyalty and satisfaction. 📜 Adapting to Regulations: Proactive compliance safeguards growth and quality. 🚀 Tech Integration: Innovations like AI show promise but demand careful execution. 💰 Value-Based Care's Rise: Aligning rewards with patient outcomes reshapes operations. As we step into 2025, the focus remains on resilience, innovation, and care. These takeaways set the stage for a robust and adaptable future. What 2024 lessons resonate most with your healthcare journey? Let’s connect and discuss! #HealthcareLeadership #InnovationInCare #2024Lessons #FutureOfHealthcare

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Recent projections from Jefferies indicate a significant shake-up for insurers: - Humana: Faces the largest hit, with an expected $2.5 billion reduction in EBITDA and a staggering $16.37 EPS drop, marking an 83% decline compared to 2025 projections. - UnitedHealthcare: Set to lose $1.6 billion in EBITDA, alongside a $1.39 EPS decline (4%). - CVS/Aetna: A relatively modest gain of $100 million in EBITDA and a $0.05 EPS bump (1%). - Elevance: A $100 million reduction in EBITDA with a $0.30 EPS decline (1%). - Centene: A positive outlier, expected to increase EBITDA by $100 million and boost EPS by $0.10 (1%).

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Here's how UnitedHealthcare steals from you And raises the cost of healthcare: Intercompany eliminations A recent STAT article uncovered some very unsurprising practices whereby UHG reimburses its physicians, employed by Optum, at rates much higher than market rates Whatever market rates are anyways And I know what you're going to ask, if UHG is paying its docs higher rates, isn't that still just taking money out of its own pocket? Why, yes, but also no Here's how it works without the effery: UHG gets $1B in premiums UHG pays $850M for medical care UHG makes $150M and satisfies MLR requirement And with the effery: UHG makes a $1B in premiums UHG reimburses $950M to its own docs The docs make $950M in revenue The docs' costs are $750M UHG eliminates $950M The real cost to UHG is only $750M UHG makes $250M UHG raises premiums next year UHG gives middle finger to MLR requirement The magic for UHG is that it gets to justify higher premiums because the "cost" of healthcare is so high It also gets to skirt right around Medical Loss Ratio rules because its own reimbursement amount is bumpkins and goes from the right pocket to the left Game. Set. Match. As Seth says, don't hate the payer, hate the game Problem is, the payers invented the game and wrote the rules P.S. If you love this hot pink graphic, you'll extra love The Healthcare Breakdown, where I use pictures with borderline offensive colors schemes to show you the games being played in healthcare Check it out here: https://buff.ly/47NeASx See you out there!

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