Shantanu Agrawal

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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We try to leverage technology in ways that superpower our people and help with the scalability of care. This is great advice from Froedtert Health’s Bradley Crotty MD MPH during Reuters #Digitalhealth24 conference. Here’s to superpowering teams and scaling care.

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Discover how the largest not-for-profit health plan in the mid-Atlantic region transformed its provider lifecycle management with V12 Network. This powerful change has revolutionized their operations, leading to a more efficient, compliant, and future-ready system. Dive into the full success story and see how innovation made all the difference: https://bit.ly/3ANmL5o #Virsys12Success

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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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Two new proposed rules could be a game changer for health data interoperability... In early July (published in Federal Register August 5), ASTP/ONC released all 1,067 pages of its proposed HTI-2 rule, in which it proposed expanding its Certification Program to complement CMS' FHIR APIs. This included creating criteria impacting payers and public health IT. It reminded me of a line of questioning from ONC's electronic prior authorization RFI from January 2022, where the agency asked nearly ten questions about what certification criteria should look like to facilitate electronic prior authorization processes. The thought then, and even at the publication of HTI-2, was that certified modules wouldn't help payers much because payers are not the ones implementing modules. The vendors who provide the administrative platforms are. As it stands, there are only disincentives to certifying under the program for payer health IT vendors (i.e., bringing them under the information blocking rule), so payers are really at the mercy of their vendors. This is in stark contrast to the impact the program has on EHR developers. That was until HHS' ASFR and ASTP/ONC released another proposed rule on August 9 that would require all providers and health plans (that means you, MA plans) that receive HHS funding to use certified health IT or adhere to ONC standards at a minimum. So, what does this mean? Payers who receive HHS funding could now have the regulatory support to require their vendors to be certified... If passed as written, payer health IT vendors that want to maintain their contracts with federally funded plans would not be able to "unreasonably limit" the exchange, access, or use of electronic health information - including charging an unreasonable fee. They could be penalized up to $1M per violation if they do. This is a huge deal. Luckily, the team at Maverick Health Policy summarized both proposals (linked below). If you need help navigating these changes, we're here to help. HTI-2: https://lnkd.in/g4McbwMy Acquisition Regulation: https://lnkd.in/gWY--VPb

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By automatically capturing patient care summaries directly to the EHR, Dragon Medical One is the speech recognition solution that fits your needs without fighting your workflow. Learn more at https://lnkd.in/e86xfcb7

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Are you inundating your patients with messages❓ Are they receiving the right information at the right time❓ Download "Your Guide to Governance," a comprehensive resource designed to help you effectively manage your patient communications strategy enterprise-wide. 𝐓𝐡𝐢𝐬 𝐠𝐮𝐢𝐝𝐞 𝐢𝐧𝐜𝐥𝐮𝐝𝐞𝐬 𝟓 𝐛𝐞𝐬𝐭 𝐩𝐫𝐚𝐜𝐭𝐢𝐜𝐞𝐬 𝐭𝐨 𝐡𝐞𝐥𝐩 𝐲𝐨𝐮: ✅ Understand the risks of over-messaging and digital fatigue ✅ Break down silos and establish a governance committee ✅ Measure, iterate, and improve your enterprise-wide communication strategy ➡️ Download the full governance guide and workbook here » https://lnkd.in/gGHjjExa #healthcare #patientexperience #digitalhealth #medtech #healthtech

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There’s no question that AI is transforming healthcare, and understanding where industry leaders perceive opportunities is important. The latest research report from Arcadia is revealing. 63% of healthcare leaders say AI can analyze large patient data sets to identify trends and create population health intervention strategies 58% say AI can analyze individual patient data to identify opportunities to improve health outcomes 47% say AI can optimize the management and analysis of electronic health records Dive into the report to gain insights from top tech leaders and see where the industry is headed! https://lnkd.in/gf_wkWij

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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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Reps. Nadler, Chu & Sen. Warren Lead Bicameral Letter to CMS Urging Oversight of Artificial Intelligence and Algorithms Used in Medicare Advantage Coverage Decisions Representatives Jerrold Nadler, Judy Chu, and Senator Elizabeth Warren, along with a bipartisan group of 45 House Members (U.S. House of Representatives) and 4 Senators (United States Senate), have urged the Centers for Medicare & Medicaid Services (CMS) to enhance oversight of AI and algorithmic tools used in Medicare Advantage (MA) coverage decisions. They express concern over AI's role in erroneous care denials, highlighting lawsuits against insurers for using AI to cut costs by denying coverage. The lawmakers call for stricter regulations, including systematic reviews of AI tools, clearer criteria for coverage denials, and limitations on AI's use until proper evaluations ensure compliance with regulations. CMS recently mandated that MA plans make individualized medical necessity determinations, but enforcement remains unclear. Advocacy groups support these measures, emphasizing AI's potential harm without adequate oversight. Read more here: https://lnkd.in/g-gJxeGn #Medicare #AI #Healthcare #CMS #MedicareAdvantage #PatientRights #HealthTech #ArtificialIntelligence #AIinHealthcare #MedicalAI #CMS #Bipartisan #MA #House #Government #WashingtonDC

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Healthcare has made improvements but there's still a long way to go to become truly digital-first. While we've seen advancements in telemedicine, electronic health records, and AI-driven diagnostics, the journey to fully integrate these technologies into everyday practice is far from complete. And the “door” to care – patient navigation – needs a lot of work. If we don't evolve, patient's will find others who do! https://lnkd.in/eSJKiHSR #patientcentricity #digitalfirst #digitaltransformation #patientnavigation

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I’ve been given advice that the fastest way to monetize HER Heard without charging the end user (woman) is trackers and selling data. Instead, I’d like to build something more trustworthy. I don’t want to be in a headline like this. If you are not paying, then you are the product (you/your data are being sold). There are newer ways to deindentify data or even to aggregate things women search for that can be of interest to various stakeholders. In theory that could be okay to sell, but in a post-Roe world with laws encouraging bounty hunting, I am vetting the choices ahead. I am all for moving fast, without breaking things.

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Our new study shares how an innovative Medicaid health plan used Peers to reduce HbA1c levels by 1.3 points (vs. 0.16 for the waitlist control)! KEY INSIGHTS: ▶️ Hyper-focus on the member's needs. SDoH, literacy, diet, etc. (which led to...) ▶️ High engagement. 16 calls & 146 min of coaching PER participant. (which led to...) ▶️ 1.3+ point HbA1c drop. This is statistically & clinically significant. --- An elevated HbA1c is just a signal that something is wrong. NOT a signal of what exactly is wrong. Trust, empathy, and time are needed to understand ROOT causes. Solving for the member's problems FIRST is the key to solving the health plan's problems. #CAHPS, #HOS, #HEDIS --- Link to the full paper in the comments.

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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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Smart Patients SmartSights: We see opportunities arising from the challenges of the recent IRA policy capping out-of-pocket drug costs for Medicare patients and the Part D redesign CMS now requires the industry to submit diverse evidence to determine treatment value. We got your back. -Cost-effectiveness analyses -Scientific quality of real-world data (RWD) -Diversity measures in real-world evidence (RWE) studies -Patient-reported outcomes (PROs) With Smart Patients SmartSights, we help you adapt your RWE strategies, ensuring agile evidence generation to meet shortened value negotiation timelines, especially with payers. Ask us how. #HealthcareInnovation #RWE #Medicare #Pharma #PatientOutcomes #PolicyChange

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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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