Rachel Laureno

Great defense of “private equity medicine” from former CMS administrator Leslie Norwalk. Though few clinicians fully understand it, PEM has become a popular bogeyman for a wide range of complaints about US health care. A few key takeaways: ·      All health care organizations require working capital. They should be judged on their behavior, rather than their source of capital. ·      Pushing health care organizations to more expensive sources of capital (e.g,, high interest loans) doesn’t serve anyone’s interests (except the banks). ·      The financial successes of private equity-backed companies accrue to everyone with a 401K or a mutual fund, not just a small number of wall street elites. ·      Reducing competition in health care (based on investment class) only accelerates market consolidation by integrated health systems, and the higher prices that come with it.

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Improve your financial literacy with this latest episode of The Bill Woodson Show where, with a guest from Kaufman Hall, we dive deep into the financial challenges faced by hospitals post-pandemic, the evolving role of CFOs, the impact of private equity, and the complexities of mergers and acquisitions in the health care sector. 

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CMS’ “Year 2” IRA Guidance Concedes Agency Patient Engagement Has Been a Bust A number of patient groups have quietly expressed frustration with #CMS’ “listening sessions” on the #InflationReductionAct “fair price” negotiations. If you read CMS’ “year 2” guidance carefully, it effectively admits the patient complaints are real and legitimate. The Complaints: Patient groups sat on the sidelines in the litigation challenging the constitutionality of the IRA, at least in part, because they believed that they could shape IRA implementation through agency engagement. But some groups are now expressing frustration. They expected CMS to explain how it was approaching negotiation and the underlying evaluation of the selected drugs. With that context, they expected to be able to provide meaningful feedback to CMS’ plans and preliminary assessments. According to the groups I have spoken to, that is not how things have gone. CMS is tight-lipped—in “listen only” mode. Unclear what CMS is considering and how it sees the “value” question, “patient interaction” on the IRA has devolved into CMS and patient groups staring at each other blankly. Confirmation: When you read the “year 2” guidance, it confirms the patient complaints. Deploying diplomatic “regulatory speak”, CMS says it “intends to improve upon the design of the patient-focused listening sessions”. Note the reference to “listening sessions”—confirming the agency has been in “listen only” mode. CMS admits the need for change, saying it “is soliciting comments from interested parties on event format, scope, and logistics”; it then indicates it “is considering events where there is discussion among speakers and in which CMS may ask clarifying questions”. But even this proposal isn’t getting to the core of the problem—patient groups shouldn’t have to be expert mind readers regarding CMS’ intent based on a few interspersed “clarifying questions”. CMS offers some other alternatives, too: “CMS is also weighing different event formats, such as round table sessions on broader topics with a mix of speaker types (e.g., patients, providers, and health data experts) or focus groups on targeted topics with one speaker type (e.g., patients or caregivers)”. But all that doesn’t commit CMS to doing any speaking. Just that others—patients, providers, and “experts” will be asked to speak. Patient groups can’t react in, or to, a vacuum. No Time: The guidance concedes that they can’t fix the problem for “year 1”. After all, July 31, 2024 is the deadline for manufacturers of selected drug to accept or reject CMS's final MFP offer. Indeed, CMS acknowledges that its proposed changes in patient engagement will be effective only “for…price…year 2027”. So, in another words, at least for “year 1”, we are going to get “fair prices” that don’t reflect meaningful patient input. #drugdevelopment #drugpricing #Medicare #managedcare #rarediseases #patientsfirst #lifesciences

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Let's keep hospice focused first and foremost on the PATIENT. After all, we only get one chance to do it right... "There are six primary trends that are influencing consolidation and professional practices: regulatory complexity. technology and integration, private equity ownership. demographics, economies of scale and consumer expectations,” Henderson said. “So many of these things that we see that are influencing health care consolidation need to be pointing toward the patient." #patientsfirst #hospicecare #youonlygetoneshot https://lnkd.in/gbbgV-YF

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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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Program Audit season is over. Join our webinar to hear all about what CMS is focusing on. If you haven’t done a mock audit now is a great time to do one and incorporate our lessons learned.

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CMS’s Enhancing Oncology Model, designed to improve patient outcomes and reduce costs, opened another round of applications in July 2024. Understand the potential benefits and financial implications of the model to determine whether participation would be beneficial for your organization and prepare for compliance and reporting requirements in this Moss Adams article by Georgia Green, MS, CHFP. #healthcare #CMS #valuebasedcare

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This 👂 podcast episode and insight’s from a16z Bio + Health's Julie Yoo spoke so clearly to the fundamental challenge facing both 🩺 clinicians and 🏥 healthcare systems.  There is a huge disconnect between supply, in the availability of clinicians, and demand, in the increasing volume and complexity of healthcare needs. -     36% of physicians plan to reduce their hours next year according to the AMA -     48% of physicians reported feeling burned out in a 2024 Medscape survey At the same time, the demographic baby boomer bubble and steady increase in the prevalence of major chronic disease, which consumes up to 90% of healthcare expenditures according to some estimates, is driving demand. With this context, Yoo points to a major opportunity for AI adoption in healthcare in 2025. Yeah, a VC hyping a wave of new AI companies that will replace the decades of training and experience of clinicians, the skeptic would say.  But Yoo is thoughtful in pointing to the role AI can play, and is already playing, through solutions such as ambient, autonomous scribe solutions (of which local star Abridge is leading the pack) in not replacing, but freeing up productivity for clinicians. There is so much unstructured context in both the complexity of disease and treatment options and the social/emotional considerations that we shouldn't be looking for AI to *replace* clinicians. But companies are getting better at finding the structured, repetitive and time-consuming places where AI tools can *help* clinicians. Nearly two-thirds of doctors cited bureaucratic tasks as the leading contributor to burnout. Rigorously trained-AI driven solutions can be a force multiplier for clinicians, and I’ve seen several interviews where nurses and doctors go as far as to say some of these solutions are ”restoring their joy in practicing medicine”. Our health is precious; and we rightly want any technology engaging with it to be developed thoughtfully and thoroughly tested. This requires top AI talent and diverse and realistic training data. Pittsburgh’s strengths in both areas is why we are an emerging hub for data-driven healthcare. #AIinhealthcare #clinicianburnout #healthinnovation #digitalhealth

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Really interesting article. ASC operations are proving crucial for the successful adoption of value-based payment systems and evolving healthcare as we know it. Strong operational foundations inherently lead to economic success and greater flexibility in adopting new care models, which in turn improves patient outcomes. #ASCs #Healthcare #PatientCare

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I’m excited to share that I’ll be presenting at the upcoming Scottsdale Institute webinar, "The Business Case for Health Equity: The 3 Rs Approach," along with moderator Alan Roga, MD, FACEP, CEO of TruLite Health and panelists Edmondo Robinson, MD, Founder and CEO, Downeast Digital; & Julie Brown-Georgi, MS, CAHIMS, Founder & CEO, Digital Health Policy Strategies. This is an important topic because although the need for equitable healthcare is increasingly clear, often leaders struggle to garner support for investments in health equity initiatives. We'll discuss how to build a compelling business case for health equity, focusing on the “3 R’s"; Reimbursement, Results and Regulatory. SI members can register for the event here: https://lnkd.in/g8Ue-z64. If you're not a member of the Scottsdale Institute, please contact @TruLite Health to be added to the webinar. #HealthEquity #HealthcareLeadership #HealthIT #DigitalHealth #HealthcareInnovation #HealthPolicy #EquityInHealthcare #ValueBasedCare #HealthSystemLeadership #RegulatoryCompliance #HealthcareReimbursement #DiversityAndInclusion #HealthcareWebinar #ScottsdaleInstitute #LeadershipInHealthcare

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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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With the recent release of CMS's Medicaid Technical Assistance Toolkit on Medical Loss Ratio (MLR) reporting, the focus is now on enhancing oversight of state-managed care programs. At Myers and Stauffer, we partner with over 20 states and CMS to ensure compliance with MLR reporting and auditing requirements. As the regulatory landscape evolves, we're here to provide the essential guidance you need. Speak with us about how we can help you navigate these complexities. Discover more about our MLR services in our latest client alert: https://okt.to/hH0M5P #MLRReporting #MedicaidOversight #HealthPlanCompliance #CMSUpdates #MyersAndStauffer #HealthcareRegulations #Medicaid

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Fiduciary responsibility is a critical component of a successful PBM RFP process, yet it often goes overlooked. In our latest video, we explore the importance of asking one key question: "Will you accept fiduciary responsibility for your representation of my client?" Learn how this question can help advisors identify PBMs that genuinely prioritize their clients' best interests and provide the accountability needed in today's healthcare landscape. #PBM #fiduciaryresponsibility #employeebenefits

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From Healthcare Financial Management Association (HFMA), here's coverage of what #hospitals and health systems need to know regarding the #Medicare FY25 final rule for hospital #inpatient care and long-term care hospitals. Hospitals will get only a small bump in Medicare inpatient payments for FY25: https://lnkd.in/gvygJtb5 Mandatory Medicare bundled payments and respiratory disease reporting are on the way for hospitals: https://lnkd.in/gthgPwRW

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An overview of the April 22, 2024, #CMS #Medicaid #ManagedCare Final Rule focused on the #financial requirements is now available. Mercer US Government's Nicole Kaufman and Charles Greenberg review the financial topics, including #ILOS, #SDPs, #MLRs and comparative #rate analyses. References to #MCOs include Prepaid #Inpatient Health Plans and Prepaid #Ambulatory Health Plans. Read the review here and download the full PFD: https://lnkd.in/d_RQt754

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I had a great conversation with Shannon Houde, MBA, PCC on how to build trust and gain buy-in with senior leadership. Check out the GreenBiz Group article below to see some of the key take-aways from our conversation!

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Check out the latest on cybersecurity and how to recovery from a breach! #IAImpact

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