Reza Alavi, MD, MHS, MBA

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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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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Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

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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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How can #Medicaid policymakers advance the adoption of value-based arrangements by Federally Qualified Health Centers? 1.     Through the Return of Shared Savings to #FQHCS. – Participating FQHC networks should be eligible to share in a substantial portion (50% or more) of the savings realized when the actual total costs incurred for their attributed population are below the benchmark or goal set for average Total Cost Of Care (TCOC). 2.     Adjust the Payment Model for the FQHC Patient Population. – The benchmark costs used to set rates should be based on the average #TCOC in the market, or the average amount the Managed Care Organization gets paid per enrollee, rather than using the FQHC networks’ own historical low reimbursement as a starting point. Learn more in this report authored by our Kim Prendergast, Aditya Mahalingam-Dhingra, and Vikki Wachino for the Milbank Memorial Fund - https://lnkd.in/eCGMECd2 #Valuebasedcare ##FQHC #ACO #TCOC #Medicare #ProspectivePaymentSystem #ManagedCare #Managedcareorganizations #VBP #Healthcarequality #CMS #healthequity #Communityhealthcenters #Communityhealth Massachusetts League of Community Health Centers National Association of Community Health Centers (NACHC)

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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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The Centers for Medicare & Medicaid Services recently announced the first states to participate in their new #PopulationHealth-focused payment model. The States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model is a voluntary, state total cost of care (TCOC) model designed to address population health in specific regions, reduce health disparities and lower #healthcare costs. States participating in this model will be responsible for the quality, coordination and cost of healthcare while receiving funding and additional tools to address current payment and equity challenges in their state. 💡 My thoughts: It's exciting to see how we continue evolving our thinking around value and innovation, looking across payers, states and state agencies to push some of these practices forward. Not only that, but the timeline of these models has also been extended from 3 years to 10 years – allowing us a longer period to gather more comprehensive learnings and understand if these interventions are having a true impact. Efforts like these help us more accurately assess if the current work we’re doing is making a difference. I look forward to following the development of this model and seeing how it plays out with the first cohort (Maryland and Vermont) in 2026! 

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Privatized Medicare Advantage plans have raised costs for Medicare by $612 billion since 2007, including $82 billion last year alone, according to congressional advisory group MedPAC. Managed Medicare membership continues to grow exponentially, while the costs to taxpayers also grows exponentially…and, these plans are the most profitable in the entire managed care sector…which should be a red flag to all consumers and healthcare professionals. #healthcare #leadership #managedcare Honor Aging

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My Friday good news celebrates the heroes of value-based care: primary care physicians and teams. The most successful #Medicare ACOs, those delivering value for Medicare and Medicare beneficiaries and sharing in that value, are primary care-centric #ACOs. We know how they do it; the playbook often includes support from enablers like Aledade, Inc.. Dr. Menard and his colleagues didn't give up when success wasn't immediate. How do we grow more primary care-centric ACOs and generate more value for Medicare and more access and quality care for beneficiaries? There are some health system ACOs investing in primary care and integrated teams. But it might take more forceful nudges from Medicare to get big health systems participating in total cost-of-care risk models. Or, we might need payment policies to give primary care more independence to practice comprehensive care. Congress could also consider restructuring the APM bonus to reward primary care "centricity". #primarycare #valuebasedcare Primary Care Collaborative David Raths David Muhlestein AAFP Foundation Thomas Culhane, MD, MMM, MS Darrin Menard, M.D. Stacey Richter https://lnkd.in/dThMvJrQ

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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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During thINc360 - The Healthcare Innovation Congress last week, I talked about CVS Health’s continued investment in health care delivery services, specifically those that provide affordability, convenience and better access to primary care. This article in Fierce Healthcare provides an overview of the discussion: https://lnkd.in/ePmzzGWh.

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I was honored to be interviewed again by MedCity News to discuss the ongoing challenges in the healthcare system—this time, focused on CVS Health. With rumors swirling about a potential breakup at #CVS, many are left wondering what the rationale behind it would be and what it might mean for the healthcare industry. In the interview, I shared my perspective: “If they were to separate, the fundamentals of the market are still [that] companies do better as they integrate their value chains. We’re seeing it all across healthcare. So they would in some sense be an outlier by trying to reverse the trend. … The question is, are the investors looking for a quick sell off to bring profitability back into the organization, or bring capital back into the organization?” What remains unclear is what this will mean for #patients and #providers. Any shift in healthcare offerings, closures, or disruptions can have serious implications for patient access and provider employment. We’ll need to closely monitor the potential separation of CVS’s retail business from its insurance and provider services and what this could mean for the future of healthcare delivery. #MedCityNews #HealthcareSystem #CVS #HealthcareLeadership #PatientAccess #HealthcareIndustry #ValueChainIntegration ESCP Business School UNC Kenan-Flagler Business School MBA@UNC ABIG Health Radiant Healthcare Meroka https://lnkd.in/dVv74QBb

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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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How Medicare Advantage is Benefiting Medicare Fee-for-Service The debate between Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) often focuses on their distinct benefits: FFS offers flexibility and broad provider access, while MA emphasizes care coordination, preventive care, and supplemental benefits. However, what is often overlooked is how Medicare Advantage has influenced Medicare FFS, driving important innovations and reshaping healthcare for all beneficiaries. Medicare Advantage: A Catalyst for Value-Based Care MA plans operate under a value-based care model, incentivizing providers to prioritize outcomes over volume. They identify high-quality, low-cost providers, monitor referral patterns, and reduce hospital readmissions. MA addresses social determinants of health with benefits like transportation and meal delivery, ensuring beneficiaries receive coordinated care. Medicare FFS Adopts Value-Based Practices Traditionally, Medicare FFS reimbursed providers based on the service volume, leaving beneficiaries to self-refer and manage their care. Influenced by MA, FFS is evolving through: • Accountable Care Organizations (ACOs) and the Shared Savings Program, incentivizing care coordination and chronic condition management. • Expanded preventive care benefits, like wellness visits and screenings, encouraging beneficiaries to actively participate in their health. Improving Outcomes Across Medicare MA’s focus on care coordination and quality improvement has proven effective, with: • Lower readmission rates • Better management of chronic conditions Meanwhile, FFS is making progress by adopting similar practices, though challenges remain. Many FFS beneficiaries still rely on episodic care rather than comprehensive management, and providers face a cultural shift to align with value-based principles. Challenges and Opportunities • MA plans: Strong care coordination but may have narrow networks and require prior authorizations, limiting specialized care. • FFS: Broader provider access but lacks MA’s systemic incentives to improve outcomes and lower costs. Conclusion The innovations pioneered by Medicare Advantage—proactive care, provider accountability, and a focus on wellness—are influencing Medicare Fee-for-Service, helping shift it from a reactive, “use-it-when-you-need-it” model to one that prioritizes prevention and care management. Together, these programs are creating a future where all Medicare beneficiaries receive better, more holistic care—no matter their chosen path. 💡 Let’s continue the conversation: How can Medicare FFS and MA work together to create greater benefits for all? Share your thoughts below! #Medicare #HealthcareInnovation #ValueBasedCare #Healthcare #Medicareadvantage #Medicareforall #Healthcareplans

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Accelerating MMIS Implementation with Newgen Software: GHIT Digital POV The Medicaid Management Information System (MMIS) is a vital platform that automates and manages the Medicaid program lifecycle. It ensures smooth administration of Medicaid services, from claims processing and beneficiary eligibility to provider management and compliance reporting. MMIS integrates business workflows with advanced technology to improve operational efficiency, maintain compliance with Centers for Medicare & Medicaid Services (CMS) regulations, and deliver better outcomes for Medicaid beneficiaries. Challenges in MMIS Implementation - While the vision for MMIS is clear, execution faces hurdles: - Complex Business Rules: Customization for state-specific Medicaid programs. - Regulatory Overload: Adapting to evolving CMS requirements and audits. - Legacy System Integration: Ensuring interoperability with outdated platforms. - Scalability: Managing the increasing volume of claims and beneficiaries. GHIT Digital, in partnership with Newgen Software, addresses these challenges with the NewgenOne Platform. This AI-powered, Low-Code, and Modular platform is perfectly aligned with the modern MMIS architecture and provides the tools necessary for efficient implementation and long-term success. Call to Action For Medicaid agencies, Managed Care Organizations (MCOs), and other stakeholders, GHIT Digital and Newgen Software offer the expertise and technology to revolutionize MMIS implementation. Connect with Monika Vashishtha, President of GHIT Digital, to schedule a personalized demo of the NewgenOne Platform and see how it can transform your MMIS deployment. MonMass, Inc. (the legal name of GHIT Digital) will work on your strategic IT Projects or Consulting requirements (NAICS codes 541511 / 541512 / 541330 / 541618). Feel free to call at 646.734.6482 or write to me at [email protected] for no obligation discovery conversation. You are welcome to share your RFPs/RPQs for us to review and respond on time. Click the Pic below to read the rest of the POV.. https://lnkd.in/eniSWN-e

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Primary care population-based payment (PBP) models are value-based payment (VBP) approaches that offer flexible, predictable provider payments, tied to quality incentives. This initiative will work with up to six #Medicaid agencies to launch/improve a primary care PBP model. Learn more: https://bit.ly/3M3sO7i

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The April final rule on #supplementalbenefits in #MedicareAdvantage is a big deal requiring immediate action from #healthplans. The Centers for Medicare & Medicaid Services (#CMS) regulations have 3 major components: evidence, eligibility and member awareness. Beginning with the CY2025 bid process, CMS will deny a plan’s bid if it hasn’t demonstrated that its proposed supplemental benefits for the #chronicallyill (#SSBCI) is reasonably expected to improve or maintain the health or overall function of its chronically ill enrollees. CMS is also implementing annual review of SSBCI offerings for compliance. To comply with the final rule, plans must do the following: ▶️ Establish an evidence-based bibliography of clinical literature for each SSBCI offering, showing it can reasonably improve or maintain the health of chronically ill enrollees. All supporting evidence must be published within 10 years of the coverage year. ▶️ Use written, objective criteria to determine an enrollee’s eligibility for SSBCI, ensuring they meet the definition of “chronically ill enrollee” with complex conditions needing intensive care coordination. MAOs must also document when enrollees are deemed ineligible to ensure equitable access to benefits. ▶️ Include an all-channel disclaimer listing the chronic conditions required for eligibility and clarifying that additional criteria may apply. ▶️ Beginning January 1, 2026, MAOs must send mid-year notifications annually each July to each enrollee with unused supplemental benefits. CMS requires the mid-year notice to support #healthequity and inform enrollees about unused supplemental benefits. These new requirements impose huge new operational challenges for plans under tight deadlines. Get cracking now. Full rule: https://lnkd.in/e8GwBmCq

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When our FDA commissioner speaks, we listen 😊 Last year, it was terrific to read his thoughts on real world data for regulatory decision making (https://tr.vet/40mjvZw). The clear thinking helped us ensure that Truveta is providing our partners the data and analytics they require to exceed FDA expectations. Last week, he opined on “Artificial Intelligence in Health Care” – but this time, I found the lack of specifics less helpful. “The FDA has authorized almost 1000 AI-enabled medical devices and has received hundreds of regulatory submissions for drugs that used AI in their discovery and development.” I expect AI is being used in some way in the discovery and development of every drug and medical device right now. The paper concludes: “The FDA will continue to play a central role in ensuring safe, effective, and trustworthy AI tools to improve the lives of patients and clinicians alike. However, all involved entities will need to attend to AI with the rigor this transformative technology merits.” It’s encouraging to see the FDA emphasize the importance of rigorous oversight. Yet, clearer expectations would provide innovators a more defined path forward. Last year, I offered some thoughts on potential guidelines in this space: https://tr.vet/48tLLeQ. Curious to hear from others on this important topic – let me know your POV in the comments 👇 https://tr.vet/3Uydt4i

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