DJ Sullivan, MBA, MHA

Exciting times at 4C Digital Health! Wilmington, Delaware - 4C Digital Health (4C), the preeminent organization delivering independent financial oversight and control solutions for self-funded employee health plans, recently announced the strategic expansion of its services into the Commonwealth of Kentucky. In late 2023, 4C successfully competed for an initial award issued by Kentucky’s Department of Employee Insurance, and Kentucky has since extended the initial contract to allow 4C to continue its important work on behalf of the Commonwealth, its employees, and its taxpayers. The Kentucky Employee Health Plan (KEHP) serves more than 288,000 members, which amounts to 1 in 16 Kentuckians. In addition, KEHP spends over $1.8 billion dollars in total healthcare benefits on behalf of its members per year and covers over 8.2 million claims per year. KEHP objectives include “improving employee health and well-being” and “providing state-of-the-art benefits while maintaining reasonable premiums.” Recognizing its important fiduciary responsibilities to its employees and its state health plan, the Commonwealth of Kentucky enacted Senate Bill 42 (2023) introduced by Senator Stephen Meredith for the purpose of ensuring that critical health plan dollars are being spent properly on behalf of state employees. The legislation requires that 4C analyze 100% of medical claims submitted for payment to KEHP; identify erroneous overpayments; and identify inappropriate or erroneous fees imposed by KEHP’s third-party administrator. Ron Templeton CEO of 4C Digital Health stated: “4C Digital Health is grateful to the Commonwealth of Kentucky for recognizing the fiduciary responsibility that state and local governments have to their employee health plans and for the opportunity to provide our services in support of this mission. We appreciate Kentucky’s goal of using 4C’s expertise and innovative solutions to improve healthcare outcomes and reduce healthcare costs for the Commonwealth, its employees, and its taxpayers.” About 4C Digital Health: 4C Digital Health (https://lnkd.in/eB-fJg4X) is a healthcare data analytics company that was founded for the purpose of developing a disruptive technology targeted at bringing transparency and honesty to the healthcare marketplace.

15

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

💡Interesting recent stat from Beckers! A consistent (3% to 5%) margin of revenue opportunity is lost due to the complexity of documenting and coding for complex inpatient cases. This uncaptured revenue is significant to a hospital's bottom line, with a 5% loss in a mid-size hospital potentially equaling $22 million to $38 million in lost revenue annually‼️ MDaudit can help with our Hospital and Coder audit workflows. Check out this short demo!

8

The conversation around the recent proposed 2.8% cut to Medicare physician payments for 2025 is intensifying. This marks the fifth consecutive year of cuts, following a 1.69% reduction in 2024 and a 2% drop in 2023. Check out the trend analysis from Hospital to Physician from the #AMA. It's mind numbing👇 https://lnkd.in/gtVN5wNa. The reality is that some physicians may be forced to leave private practice and become employed physicians due to these financial pressures. Unlike private equity-backed groups, some private practices often lack the financial support to absorb these cuts. If you're facing this dilemma, as some of my clients are, my advice is to tread carefully and do thorough research. Analyze your reports and evaluate whether your practice can survive despite these reductions. I've also noticed that many practices still face unnecessary denials from non-Medicare payers, which, if addressed, could help offset these payment cuts. Additionally, there are often inefficiencies within staff roles where technology could boost productivity. Before making the leap to becoming employed, consider all the implications. And if you must make that transition, ensure you secure a solid contract. Make sure the CFO understands your needs and rights, and that they have a capable billing and coding team that will accurately capture the RVU value you're entitled to. I'm always here to advocate for physicians. 💪 #HealthcareAdvocate #MedicareCuts #PrivatePractice #PhysicianSupport

12

5 Comments

Proof of Purpose; PDPs kept afloat Good for Manufacturers, too? The intricacies of IRA Part D benefit redesign dramatically reshape the OOP for millions of beneficiaries, reducing financial toxicity and raising utilization (I will post to past non adherence figures in comments) Unlike MA PDPs, freestanding PDPs can’t shuttle money over from the medical benefit to moderate premium increases, so some speculated that PDPs would fail. I commented several times that given this administrations view of the private market exemplified by MA that was highly unlikely. And after all PDPs are holding up half the benefit. CMS moves forward. “CMS is also announcing a voluntary demonstration program for standalone prescription drug plans (PDPs). The Part D Premium Stabilization Demonstration is designed to test whether additional policy changes stabilize year-over-year changes in premiums for participating standalone PDPs, leading to more predictable options for beneficiaries during the initial implementation of the IRA’s) benefit improvements, creating more gradual enrollment changes… Under the voluntary demonstration, there will be a reduction in the base beneficiary premium of $15 for all participating PDPs, combined with a year-over-year plan premium increase limit of $35 and narrowed risk corridors..” Thanks Tom Thoughts on implications, such as spillover from reducing headwinds, moderating adoption of narrower formularies and networks? If so possible plus for Phrma —not to mention if it slows down MA train with attendant Part B drug prior auths. #PartD #PDPs

5

2 Comments

🔥Really big news out of Centers for Medicare & Medicaid Services right now with their plan for payments from the government to MA plans expected to increase on average by 4.33%, or over $21 billion, from 2025 to 2026, as proposed. 📰 The news is much needed as Medicare Advantage has faced two years of flat reimbursement growth from CMS that has Humana down 43% in the last year along with CVS Health down 44% that leaned into MA last year. 💵 Humana is up big (4.5%) in after hours trading along with UnitedHealth Group up 2.5% as they UNH is the largest Medicare Advantage provider with over 7.8 million lives (3 million pdp) while Humana is second with 6.2 million lives (2.3 million pdp/8.5 million total). CVS Health is up 2% in after hours trading as well which is a nice shift for them. ⬇️ Medicare Advantage was one of the hottest lines of business in healthcare but over the past 6 quarters seniors have experienced high utilization post COVID, reimbursement was starting to slow as there was a 5.0% increase in 2023, 3.32% in 2024, and 3.7% for 2025. This 4.33% increase is a big unexpected tailwind for Medicare Advantage providers. UnitedHealth Group, Humana, CVS Health, Elevance Health, Kaiser Permanente and Centene Corporation are the largest providers of Medicare Advantage in the US so this will be good news headed into the weekend! Nice little shot in the arm for HCSC which is expected to close on the 600,000 member Medicare Advantage business from The Cigna Group in Q1! Interested to hear comments this week J.P. Morgan Healthcare Conference in San Francisco #healthcare https://lnkd.in/g2qZTaxM

37

The 2025 Inpatient Prospective Payment System (IPPS) final rule is out. These rules are always long and this one is no exception, but here’s some interesting bits I pulled out for CDI and coding professionals. Acute care hospitals will receive a 2.9% payment bump. Adoption of portions of the new mandatory alternative payment model, TEAM (Transforming Episode Accountability Model). See p. 21 of the final rule below for details. New CC designation of seven ICD-10-CM codes that describe inadequate housing and housing instability. These fall in the Z59 series. Four new MCCs, including: ·     I26.03 Cement embolism of pulmonary artery with acute cor pulmonale ·     I26.04 Fat embolism of pulmonary artery with acute cor pulmonale ·     I26.95 Cement embolism of pulmonary artery without acute cor pulmonale ·     I26.96 Fat embolism of pulmonary artery without acute cor pulmonale 104 new CCs, too many to list here but primarily codes related to lymphoma types (C81-C88 series), anorexia and bulimia (F50 series), epilepsy, GI repairs, and of course the inadequate housing codes above. Your friend is Table 6J.1. 18 deleted CCs, mostly non-specific codes that are now included in the new CC list Seven new quality measures, deletion of five quality measures, and modification of two measures in the Hospital Inpatient Quality Reporting Program. Note that these measures can be impacted by more than just clinical care; accurate diagnosis and procedure coding can move patients in and out of them. Seven new measures: ·     Hospital Harm – Falls with Injury eCQM, with inclusion in the eCQM measure set ·     Hospital Harm – Postoperative Respiratory Failure eCQM, with inclusion in the eCQM measure set ·     Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications ·     Patient Safety Structural Measure ·     Age Friendly Structural Measure ·     Catheter-Associated Urinary Tract Infection Standardized Infection Ratio measure stratified for oncology locations ·     CLABSI Standardized Infection Ratio measure Modified measures:   ·     Global Malnutrition Composite Score eCQM (now includes patients ages 18 to 64 to the current cohort of patients 65 years or older) ·     Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Deleted measures. These include Hospital-level, Risk-Standardized Payment Associated with a 30-Day Episode of Care for: ·     Acute Myocardial Infarction ·     Heart Failure ·     Pneumonia ·     Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty CMS is also removing PSI-04, Death Among Surgical Inpatients with Serious Treatable Complications measure, replacing with the new Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications measure. The Hospital-Acquired Condition (HAC) Reduction Program and Hospital Readmissions Reduction Program remain unchanged; minor tweaks were made to the Hospital Value-Based Purchasing (VBP) Program.

45

3 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

After more than 20 years in healthcare, particularly in the middle revenue cycle, I've had a front-row seat to the transformation of patient care. We’re at a pivotal moment where acute care should be the exception, not the rule and investing in ambulatory care sectors is needed. The financial pressures on hospitals and payers are immense, and with U.S. healthcare costs soaring—$14,423 per person in 2023, projected to hit $15,074 in 2024—it's clear that we must rethink how we care for patients. 💡 The solution? Innovation and a shift to preventive care. U.S. healthcare spending rose by 7.5% in 2023, reaching a staggering $4.8 trillion, far outpacing the GDP growth rate. Embracing clinical decision support tools and investing in ambulatory care settings is key to bending the cost curve. 🌟 I transitioned into consulting to help health systems thrive amidst these challenges, and while some progress is being made, there’s still a long way to go. Now is the time for health systems to double down on innovation and ambulatory care to ensure a sustainable future for all. Let’s lead the change! 💪 Becker's Healthcare #HealthcareInnovation #AmbulatoryCare #PreventiveCare #HealthcareLeadership https://lnkd.in/gGaNQFCi

40

7 Comments

MEDICARE BUDGET NEUTRALITY ISN'T VERY NEUTRAL A new survey's findings show that physician reimbursement has per patient decreased by 2.3% between 2005 and 2021. KEY TAKEAWAYS Findings show that patients saw a 45.5% increase in services, compared to the 2.3% decrease in physician reimbursement per patient. Providers have been vocal in their opposition of the slashed Medicare rate, which was finalized in March. The impact of the trend of decreasing Medicare reimbursement for provider services hits home when one's parents have trouble scheduling neurology and gastroenterology consults due to providers no longer accepting Medicare, reimbursement is too low. Years of decreasing Medicare reimbursement eventually caused physicians to make a business decision to limit or no longer accept Medicare patients. Something needs to give, the good news is the solvency of the Medicare Trust fund is now extended to 2036. #Medicarepayment, #lowreimbursement, #decreasingreimbursement, #nopayraise https://lnkd.in/e8fBYkV7

6

1 Comment

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

4

4 Comments

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

7

I hole heartedly agree Benjamin Schwartz, MD, MBA. Anywhere else in an economic system, innovators who can deliver a better product at lower costs are almost always rewarded with greater market share, and frequently set the direction for the future of a product or industry. Not so in healthcare. I think that Terry Adirim, MD, MPH, MBA (below) hit the nail on the head when she references for-profit health insurers in the mix. Although policies have been enacted with the idea of providing better healthcare at lower costs, they have always given the job of administering those policies to a middleman (insurance companies) whose motives are at odds with the objective they claim to be administering. Profit! Innovation is not in the best interest of the payer. They profit through the inefficiency of the system. Until this lack of alignment between quality patient care at low costs and for-profit health care plans is addressed, process innovation and improvement will only be able to nibble at the edges.

2

Purchased services are vital to healthcare, but they can also become financial drains if not managed properly. A mature purchased services strategy includes insight into all expenses, reduction in unnecessary variation, and prioritized patient care, outcomes, and experience. By focusing on these areas, health systems can lower costs, improve clinical care, and enhance patient experiences. Learn more in Advantus Health Partners article about how to create a mature purchased services strategy: https://lnkd.in/g4UwCjCW #HealthcareSupplyChain #ValueBasedCare #SupplyChainManagement

37

Did you know that in the proposed rule, starting July 1, 2025, agencies will be required to submit OASIS on all patients regardless of payer? There is a 6-month period where it's voluntary to do so, and then mandatory as of 7/1/25. Exceptions include patients under 18 and those receiving personal care, but all OASIS submissions will now impact your agency's outcomes. "This change includes shifting data collection to begin at the start of care (SOC) time point. The SOC assessment, the first for non-Medicare/non-Medicaid patients, can be submitted either on or after Jan. 1, 2025, during the voluntary period or on or after July 1, 2025, for the mandatory period." Have questions? Feel free to reach out to me! Stay informed to ensure compliance and effectively track your agency's outcomes. #Healthcare #OASIS #Compliance #bartlettstrategygroup https://lnkd.in/exWTxnwA

5

1 Comment

Bigger isn't always better in healthcare. Just look at the graphic below. Some of the largest health systems in the country are underperforming. They've entered (or operate in) bad markets, hold bloated cost structures, and struggle to hold leverage against payors. As it turns out, and as I'm often reminded, market performance matters. It doesn't matter that you're just big and can absorb a vast swath of overhead. As a health system, the way you throw your weight around in markets is more important than ever. This is the key concept of density and having the right assets in the right markets. CVS, HCA, Tenet, and others all have mentioned the importance of market density in 2024. Density - and being dense in attractive markets - is primarily what separates -3.9% from 10%+ operating margins. I should have paid attention in physics!! PS: if you like graphics and analysis like this, subscribe to my newsletter Hospitalogy here with 34k+ others: https://lnkd.in/gniNmHvz

161

15 Comments

Now that the health plans have all submitted their Medicare Advantage bids for the 2025 calendar year, I thought it would be worth bringing up a recognized problem in the CMS Benchmark calculation (United States Per Capita Cost or USPCC) that falsely lowers the benchmark. If you aren’t familiar with how these benchmarks are calculated, I wrote a simplified explanation last month which you can find here: https://lnkd.in/gSmvq9mB The first step in calculating this benchmark is for CMS to add up the risk-adjusted monthly total fee-for-service spend for all Traditional Medicare beneficiaries and get an average spend per beneficiary per month. The thing is, they include beneficiaries that only have Part A (institutional expenses) but not Part B (professional expenses) as well as those that only have Part B and not Part A. Obviously, that means they’re counting people where a meaningful portion of their medical expenditures are not included as if they’re the same as people where all of their spend is included. In effect, this lowers the average monthly cost per beneficiary. Yet, this is the benchmark that is used to represent the cost to manage the combination of all Part A and Part B expenses for a population. That is, the MA bids have to cover both Parts A and B for their whole population but it is being compared to a benchmark where some of the people only have one or the other. Even MedPAC has recognized this issue and calculated in 2017 that if they were to only include beneficiaries with both Parts A and B, it would raise the benchmarks by about 1%. This fact tends to be ignored in the news articles decrying the higher spending in MA when compared to Traditional Medicare. #MA #MedicareAdvantage #Benchmarks #ManagedCare #Medicare

31

2 Comments

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

6