Ethan Berke, MD, MPH

Our work on differences in Home Health utilization and outcomes between Medicare Advantage and Traditional Medicare continues to inform the conversation in healthcare media: https://lnkd.in/gWY-9vYe

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Another important position statement from Association of Healthcare Value Analysis Professionals (AHVAP). As value analysis evolves, it is vitally important to ensure that those who are entrusted with the process understand what is expected of them in terms of professionalism. Please feel free to share this important document.

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Medicare Advantage (MA) impacts patients and providers significantly. For patients, it involves hours wasted on prior authorization requests, limited access to physicians due to narrow network plans, and high healthcare costs for underinsured beneficiaries. Providers face challenges with the administrative burden of prior authorizations and negative outcomes for patients, including increased likelihood of death after certain surgeries for MA beneficiaries

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Measuring Quality of Care Quality matters. Better health for everyone should be America’s goal. Where you live and receive your healthcare services makes a difference in your health.   Fortunately, objective understandable quality metrics are now easily available at https://lnkd.in/eVQyZ2E6. This easy-to-use website created by the federal government to help potential patients facilitate comparisons among hospitals is based on a variety of the more than 100 measures CMS publicly reports, divided into 7 measure groups or categories: Mortality, Safety of Care, Re-admission, Patient Experience, Effectiveness of Care, Timeliness of Care, and Efficient Use of Medical Imaging. Adding rationality to decision-making in determining where to go for care has the added benefit of improving performance for all hospitals because every healthcare system will have the extra motivation to improve its “grades.”   Better performance also translates system-wide to fewer complications, decreased waste, and lower costs. All these attributes contribute to a healthier America and the ability to transfer resources previously regarded as “waste” in healthcare to other worthwhile endeavors such as education, infrastructure, safety, and environmental protection.         Healthcare is the largest industry by far in America, consuming 18.3% of the GDP at $4.5 trillion dollars and growing. If the U.S. healthcare industry were considered a country, it would be the fifth largest in the world behind the U.S., China, Japan, and Germany. U.S. healthcare is larger than the United Kingdom. U.S. healthcare perennially ranks last in healthcare of the eleven most developed nations.     Healthcare systems living off a past reputation and perceived greatness, embellished and polished by extensive marketing, are no longer rational, effective, or fair to a naïve, stressed sick person. The most venerable institutions are now the most vulnerable.   Clear metrics such as heart failure, heart attack, pneumonia, and post-operative mortality rates objectively differentiate potential outcomes based on where you go for care. All this data is adjusted for age and severity of illness and, although the system is not perfect, it is the best we currently have, with all institutions having the same grading system.   Additionally, and arguably, even more important than being a repair shop, alert healthcare systems should be focused outside the four walls of their institutions. Sadly, our nation’s life expectancy has decreased in the last few years. This decline hasn’t happened since 1963.   Life has changed. Where you get care matters. Do your homework and add to your life expectancy. America can have better care for everyone now using accessible digital transparency.

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📢 Important news! MNCM and DHS have released this year's report on Minnesota Health Care Disparities by Insurance Type, focused on care delivered in 2022. A key goal this year: Boosting awareness about the availability of these crucial data. State government, health plans, and health care providers leverage these reports to shape strategies for advancing health equity. Yet, we recognize that many others—especially those driving local community efforts to combat disparities—may not be fully aware of these resources. By widening the dissemination of these reports, we aim to spark fresh dialogues on how this data can empower community-based organizations and local public health agencies in their vital work. Your assistance in sharing this information within your local networks is invaluable. Special thanks to Kate Hust, Clarence Jones, and Mariam Mohamed for sharing your insights on community context and engagement strategies. Kudos to Jess Donovan, MPH, BSN, Ma Xiong, and Alyssa Ida Pintar Breen for your outstanding work on the analysis and production of the report! #HealthEquity #CommunityHealth #DataDriven #MinnesotaHealthcare #PublicHealth #HealthDisparities #LocalEngagement

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Stop by and say hello and check out the ways we can help with your health equity analytics and dashboard design and development!

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Why big is bad in healthcare: Some interesting comments here on health system consolidation from Andrew Donahue, FHFMA, CPA, HFMA's director of health finance policy. Keep in in mind that this is someone who's extremely sympathetic to the hospital industry. First, he acknowledges that mergers "can lead to less competition, inferior service and higher prices" and goes on to say that the only driver of hospital mergers is private insurance companies giving better rates to bigger systems. In an accompanying interview on HFMA's "Healthcare Blame Game" podcast, Donahue goes even further: "Community healthy systems do not want to be megasystems...growth is not necessarily the strategic imperative...you lose local control." He talks about "megasystems" laying off local staff and cancelling contracts with local suppliers, both of which can be devastating to communities. "The corporate finger can slip off of the pulse of the local community when you have more bureaucratic layers, channels, and processes to navigate." This is a message that needs to be heard across the healthcare industry. Hospitals exist to serve communities, not corporate offices in distant locations. Corollary message: Private insurers, both for-profit and non-profit, have s***-ified the hospital industry with their contracting practices. #ethicalhealthcare #hippocraticcapitalism #hospitals #healthsystems #monopolies #antitrust

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🏥 Extending Hospital at Home: A Bipartisan Initiative 🏥 Senators Tom Carper (D-Del.) and Tim Scott (R-S.C.) have introduced the Hospital Inpatient Services Modernization Act of 2024. This pivotal legislation aims to extend the CMS Acute Hospital Care at Home waiver program for five additional years. Here's what this means: - **Continued Success**: The program has shown to reduce healthcare costs, improve patient outcomes, and alleviate hospital burdens. - **National Reach**: Currently active in 37 states, including Delaware and South Carolina, with the program set to expire on December 31, 2024. - **Home Care Benefits**: Enables Medicare beneficiaries to receive hospital-level care in the comfort of their own homes. - **Bipartisan Support**: This extension builds on prior successes and bipartisan efforts to innovate healthcare delivery. - **Healthcare Evolution**: ChristianaCare has successfully admitted over 1,000 patients, showcasing the effectiveness and patient satisfaction with home-based care. 🗨️ "Our efforts aim to revolutionize healthcare by allowing vulnerable Americans to receive high-quality care at home, reducing traditional hospital risks," said Senator Scott. Take a look a the bill here: https://lnkd.in/ge4CMpx8 #HospitalAtHome #HealthcareInnovation #BipartisanHealthcare #Medicare #HomeCare #PatientCare #HealthPolicy #ModernMedicine #SeniorCare #CMS 👩‍⚕️🏡 Let's support the future of healthcare, where home is where the healing happens!

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Managing prior authorizations across all lines of business is easier when you have a single source of truth. PA Checkpoint becomes that source of truth for our clients - listen to BCBS of Minnesota share their experience: #PriorAuthorization #AIinHealthcare #ItilitiHealth

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Thoughtful, complete primer by Center for Health Care Strategies on how to develop primary care population-based payment models in Medicaid. Recommended reading for Medicaid policy makers, as well as those operating in the government program value-based space. I've spent a lot of time thinking through how to bring value-based care to Medicaid, feel like the authors identified most, if not all the key elements. I think risk adjustment, as identified in the primer, is what can move this from theory to reality. As we know states their need to close the books annually, so a key challenge is creating a risk adjustment methodology that meets VBC goals and keeps the program on budget. Appreciate the suggestions of both medical AND social risk adjustment as an approach. Loved this quote, "When developing a social risk adjustment methodology, it is important for states to understand their goals for the adjustment: Is it to predict costs as accurately as possible or increase investment in primary care? Could it be both? Or are there potentially other goals to consider?" Would Centers for Medicare & Medicaid Services ever consider have federal dollars pay for Medicaid risk adjustment?

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Earlier today, #CMS issued a #Medicaid Final Rule codifying existential Quality, Access and Accountability requirements. Among other things, these new rules improve #AccessToCare and #HealthEquity by: ⏩ Creating a mandatory MCD Quality Ratings System (#QRS) containing 18 required #HEDIS & #CAHPS measures which mirrors #MedicareAdvantage & #Exchange #StarRatings programs and requires public display of ratings online  ⏩ Requiring 10- or 15-day maximum wait time standards for routine appts for OP MH/SUD, #primarycare, OB/GYN & 1 add’l state-chosen service ⏩ Requiring MLR reporting, and minimum 85% MLR if states set a minimum MLR target ⏩ Expanding/encouraging #VBP, #VBC and #APMs and codifies Provider Incentive requirements ⏩ Adding guardrails and clarity for use of ILOS, including enrollee rights/access and oversight (the MCD version of #SupplementalBenefits in #MA) ⏩ Codifying #QualityImprovement expense criteria  ⏩ Expanding/strengthening network adequacy and benefit/service availability requirements These rules require Medicaid MCOs to ensure actual access exists for the care and services beneficiaries are entitled to. Just as we've seen recently with CMS changes to #MA, #PartD and #Stars, today’s FR change the game. Especially in combination with the 2027/2030 #DSNP Alignment rules in the 2025 MA FinalRule, these new requirements represent the most change in MCD accountability in decades. Here are 3 practical things Medicaid plans can do immediately for success: 1️⃣ Identify a silo-buster. CMS is aligning programs to minimize burden. It will be hard, if not impossible, to be profitable and highly rated if MA and MCD use separate processes, vendors, provider incentives, etc. It will be even harder to pass along product-specific provider accountability via risk/VBC without cross-program synergy/alignment. #Silobust relentlessly! 2️⃣ Educate, re-educate, re-skill & up-skill. These 284 pages, combined with the 182 in this week’s Nondiscrimination FR and last month’s 1,327 page MA FR can’t be understood or operationalized in your team’s ‘spare time.’ Every person in every team needs to understand the #NewNeedsOfFederalFunding so daily decisions meet new regulatory requirements. 3️⃣ Know your communities, know your providers and know your members. #NextGen solutions in both MA and MCD will require us to know and understand the communities and patients we have the privilege of serving. CMS understands the seismic impact of these rules, and is giving multiple years to come into compliance with the #NewNeedsOfMedicaid. Adaptation will require every bit of the long runways, though it will be tempting to slow-roll transformation since the timeline is long. #WhatGotYouHereWontGetYouThere #Transformation > #TinyTweaks #LetsRoll ⭐ ⭐ ⭐ ⭐ ⭐

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HHS-OIG impact brief: Prior authorization requirements in #Medicare Advantage occasionally obstructed enrollees' access to vital services, resulting in delays or denials that could adversely affect their health. Learn more: direc.to/fhYq

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Here's a shocker -- the AHA and the FAH are pushing back against Medicare's mandatory hospital-based bundled payment program. The hospital associations are asking for more time to get ready for a program that will start in 19 months.... It's laughable, of course, but what else should we expect from the agents of the status quo? For those who hadn't kept up, Medicare announced the Transforming Episode Accountability Model several months ago and it's finally going through the end of the rulemaking process. So what's TEAM? A slimmed down version of the Medicare Bundled Payment Model (BPCI and its successor BPCIA) that has been in place for over a decade. There's nothing new about TEAM except that it only covers a handful of inpatient stays and the accountability is reduced to 30 days post discharge instead of 90. Four years ago a dozen or so highly respected leaders in the industry recommended that CMS institute a "DRG+30" across the board. Not just for five DRGs, but all DRGs. And here we are, four years later, and TEAM is set to start in 2026....yes, 2026, not 2025. The first cohort of the original program launched in April 2013, more than 11 years ago. By the time TEAM starts it will have been close to 13 years. Isn't that enough time to get ready Chip Kahn???? All of the published analyses on the Medicare Bundled Payment program showed the same source of savings -- post-acute care. And the savings never negatively impacted outcomes. So it's logical that Medicare makes this mandatory. What's not logical is that it's taken so much time to get to this decision. So let's just get on with it because the taxpayers deserve it and so do Medicare beneficiaries. #TEAM, #BundledPayments, #CMMI

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A recent Better Medicare Alliance survey found that Medicare Advantage (MA) beneficiaries in rural areas save more on health care costs and are more likely to use preventative care services, such as mammograms and annual check-ups, than their Medicare fee-for-service (FFS) counterparts.   In particular, the analysis, which was conducted by ATI Advisory, noted the average Medicare FFS enrollee spends 49% more on premiums and out-of-pocket costs compared to MA beneficiaries. This study is significant as the number of MA enrollees in rural areas has quadrupled since 2010. Today, 40% of all eligible Medicare beneficiaries in rural counties are in MA plans. For more information about the report, visit: https://lnkd.in/gEXZcrsy #medicare #medicareadvantage #seniorcare #healthcare

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No Surprises - The majority of the NSA-eligible claims were resolved through an initial payment—5.2 million based on the survey and 8.0 million based on national estimates. Less than a quarter of the claims entered the 30-day open negotiation process, most of which (73 percent) were resolved without initiating the IDR process. CMS estimated the number of 17,000 claims would enter the IDR process each year. 334,828 disputes were initiated between April 15, 2022, and March 31, 2023, a figure almost fourteen times greater than the agency’s estimate. After proposing new regulations related to the IDR process in October 2023, the government predicted 420,000 initiated disputes for the next year. However, AHIP and BCBSA estimated that nearly 670,000 claims were submitted to the IDR process between January 1 and September 30, 2023, and this figure is not likely to have peaked yet. Use of IDR process is anticipated to grow. How is the air ambulance industry fairing under no surprises? If you are an Air Ambulance provider who’s interested in learning more about pathways to in-network participation and improving your cash flow contact me. #nosurprisesact #airambulance #ambulance

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Did you know 90% of our $4.5 trillion healthcare spending goes to chronic and mental health conditions? As healthcare costs continue to rise, physicians, group practices, and hospital systems need to focus on effective chronic care management (#CCM) strategies to coordinate care, improve patient outcomes, and create sustainable financial models that successfully navigate the future of #healthcare. My latest post, with good friend Greg Fulton, dives deep into the benefits of integrating CCM into value-based care models. We explore how new Centers for Medicare & Medicaid Services guidelines for concurrent reimbursement, the impact of care coordination on patient costs, and how implementing CCM can significantly enhance revenue and patient care quality. Discover how strategic use of #MIPS and ACOs can also significantly boost your revenue and strengthen your negotiation power with payers. Read on to learn why CCM is your key to a more profitable and sustainable healthcare practice. Let’s start building a healthier future today! Read the full article here => https://lnkd.in/eD5u9bww #CCM #RPM #TCM #BHI #CoCM #RTM #PCM #CPM #CEO #CRO #Strategy #Leadership #Growth #Innovation #JustinBarnes #HITAdvisor #StrategicPlanning #DigitalHealth #HealthTech #HIThinkTank #ServantLeadership Healthcare NOW Radio Answers Media Network SiriusXM Spotify

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Do Medicaid recipients get the same care as Medicare recipients? In a new paper with Calvin Ackley, Abe Dunn , and Eli Liebman we find that Medicare recipients recieve 20% more services than Medicaid patients, including high-value care. We track over 22 thousand Medicaid recipients who become "dual enrolled" in Medicare when they turn 65. Dual-enrolled Medicare patients rarely face any out-of-pocket expenses (nor did they when they were on Medicaid) so there are likely to be minimal demand side-effects when they switch from Medicaid to Medicare. Most of the change stems from physicians who are "Medicaid Averse" which we define as a provider who did not see any new Medicaid patients over the last year. This means Medicaid's smaller network size, including Medicaid aversion, is a driving force in limiting services. https://t.co/eXEaHybuz0 #healthcare #medicare #medicaid

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Payments for pediatric hospitalizations oftentimes don't cover the cost of care. Over 50% of pediatric discharges in the country are paid by state Medicaid programs. For some children's hospitals, it could be 75% or more. For the same diagnosis, Medicaid pays 20%-50% less than Medicare rates and orders of magnitude less than commercial (PPO) payers. The map below shows your state's Medicaid payment model. If you have any percentage of peds/NICU discharges that are paid by the DRG method (some commercial payers pay by DRG as well), you need to ensure your Clinical Documentation Integrity (CDI) team is reviewing those cases. Given the chronic underpayment for pediatrics, hospitals should be using their CDI teams to optimize severity-adjustment, CMI, and hospital reimbursement for this patient population. Pediatric Resource Group (PRG) is the only pediatric focused CDI consulting firm in the country. Our team has assessed, developed, optimized, or leads dozens of CDI programs at academic medical centers and community hospitals. Let us help you improve the financial health of your peds/NICU cases so you can expand the care provided to the neonates and children in your community. #healthcareconsulting, #CFO, #revenuecycle #CDI #pediatrics

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📌 We need to identify and remove bad friction to simplify workflows in health care and improve the human experience for our care team members AND our patients. Imagine if all health systems invested in identifying and removing bad friction in EHR workflows doing these 6 things shared by the American Medical Association. 1️⃣ Identify the pain points 2️⃣ Ask the “why” of the current state 3️⃣ Prioritize the work 4️⃣ Change the EHR inbox workflow 5️⃣ Eliminate, automate, delegate, and collaborate 6️⃣ Remove items that don’t add value #RethinkAndRedesign #SimplifyTheEHR #HumanCenteredWorkflows

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