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Miami, Florida, United States
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William Sarraille
Sooner than You Think: When Will the #340B Program Be the Largest #Drug Program in the Country? The IQVIA 340B report is chock full of great info on what is happening in 340B. But, with some other data, it points to how fast 340B will be the largest drug program in the country—bigger, even, than #Medicare #PartD. Main Takeaways: The report tells us that: • In 2023, 340B sales were $124.1B. • 2022 to 2023 growth was an astonishing 16.5%. • 5 year growth was a more astonishing 129.4%. • Those growth rates were (can we be more astonished?) more than 3x the growth rate of non-340B sales. • #Hospitals and #clinics increased 18.9% year-over-year and retail and mail channels was up 10.2%, “despite ongoing #contractpharmacy restriction[s]”. • The average 340B discount was 55%. • 2023 340B profits/subsidies were $56.1B. But Where Are We Headed?: Good question. I applied the current growth rate of 16.5% to the current 340B sales of $124B and compared that result to Part D gross spend by the government in 2021, marked up by the average growth rate for Part D from 2016-2021. Based on the current rate of increase in the 340B program, the 340B program--already the second largest drug program in the country--will be the largest program, eclipsing even Part D, in just 6 years. At that point, 340B sales will be in excess of $310B a year. Applying the current relationship between 340B sales and 340B profits/subsidies ($124.1B to $56.1B), that would mean that, in 6 years, 340B profits/subsidies would be in excess of $145B. In any program that even approaches that size, patients should receive drugs without any #costsharing where their income is less than 300% of the federal #poverty limit, all patients should have cost-sharing determined based on net (not inflated) gross prices, and 340B hospitals should have a set obligation to provide a designated percentage of revenue to charity care, without fail. It is unconscionable that federal reform proposals and state contract pharmacy laws fail to include these basic patient protection provisions. The 340B program must put the #patientfirst, beginning with that patient at the #pharmacy counter, whether they seek #medication for a #chronicdisease or a #raredisease. It’s the right thing to do, and we should do it now. #managedcare #charitycare 3charities #financialneed #allcopayscount #copays #costsharing #fpl #access #affordability #rarediseases #lifesciences
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8 Comments -
Fawad Butt
I'm sure everyone is aware of this news, but just to make it clear: The payers are in trouble. Profitable growth will not return until they find ways to reduce operating, back-office, and administrative costs, because high Medical Cost/Care Ratios are here to stay. As someone who has been privy to large payer operations, I can say there is significant room for improvement. However, bureaucracy and slow technology adoption continue to be major impediments. Luckily, the document-based, fax-oriented healthcare business model has the potential to overcome some of the most manual and mundane back-office problems by utilizing GenAi and LLMs, resulting in 200-400 basis points of additional profits. Yet, the inclination to develop their own solutions, or the desire to align with big brands like OpenAI, Microsoft, and Google, will likely result in nothing more than press releases and superficial market strategies. I worry that their natural tendency to cut costs by reducing headcount will perpetuate the inefficiencies, create backlogs, and ultimately reduce quality of care. #healthcare #healthinsurence #cvs #aetna #genai #llm #artificialintelligence #ai #technology #deeplearning #tech #innovation #data #dataanalytics #business #datascientist #automation #analytics #medicare #carequality #backoffice https://lnkd.in/g9Dbqacs
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16 Comments -
Michael Nadeau, P.Eng.
Walmart Exits Healthcare Market: RPM Steps Up to Fill the Gap... Walmart's departure from the healthcare market, including its virtual health care services, will leave a void in care services for underserved communities. While hospitals and primary care providers (PCPs) remain the backbone of our healthcare ecosystem, their resilience is rooted in the trust relationships they've built with patients. This trust is a cornerstone of effective care, and RPM can help hospitals and PCPs extend their reach. RPM uses digital technologies to monitor patients' vital signs, health data, and other relevant information remotely, enabling healthcare providers to deliver timely interventions and preventive care. By leveraging RPM, we can: - Increase access to care for underserved communities - Detect health issues early, preventing complications - Deliver personalized care plans - Reduce healthcare costs - Empower patients to take a more active role in their healthcare As we move forward, RPM can help address the disparities in healthcare access and ensure that everyone has access to quality care, regardless of their zip code or background. Let's harness the power of RPM to create a more equitable and accessible healthcare ecosystem! #RemotePatientMonitoring #Telehealth #DigitalHealth #HealthcareAccess https://lnkd.in/eD7CcaEm
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Adam Brown, MD MBA
CVS Health's CFO made a striking confession: "The goal next year is margin over membership". He then explicitly acknowledged the potential loss of up to 10% of their Medicare members to bolster financial margins. What does this mean? In plain terms, one of America's largest healthcare giants, with projected annual revenues nearing $360 billion (still 10% more than last year), is considering reducing its patient base—yes, **patients** (aka members)—under its #MedicareAdvantage plans. This decision comes as a result of growing "utilization pressures"- a payer euphemism indicating that more people are seeking the care they desperately need. And what were those "utilization pressures"? Increased outpatient services, outpatient pharmacy, and behavioral mental health services (healthcare). Big Picture: CVS Health isn’t just any company. It's a behemoth with sprawling operations, including Aetna, a CVS Health Company (a major insurer), CVS Caremark (a leading pharmacy benefit manager), and a vast healthcare workforce through CVS MinuteClinic and Oak Street Health. Despite these extensive resources and their near-monopolistic vertical in the healthcare industry, the focus turns to profits over patients (aka margins over members). The Problem: Incentives. Medicare Advantage insurers and administrators love the upfront capital from Centers for Medicare & Medicaid Services (aka taxpayers), but really dislike it when patients actually need to use their services (which drains their capital) or CMS cuts their reimbursement due to quality concerns. To maintain profitability, they have three options: 1) shed members or 2) make it even more difficulty for patients to use services or 3) all of the above. And here's the problem, all options are bad for patients. Folks, it's beyond time to question the incentives embedded within our profit-drive health insurance system and in Medicare Advantage. We have to critically evaluate how business decisions by CVS (or United Healthcare or Humana) ultimately affect patient outcomes and #provider practice. To be clear, margins are necessary because it's true "no margin, no mission", but when a company can openly prioritize margins with potential repercussions for vulnerable, senior populations, it highlights the profound misalignments between healthcare needs and business strategies. #Healthcare #CVS #MedicareAdvantage #BusinessEthics #PatientCare ABIG Health Matthew Raffa MBA Meroka UNC Kenan-Flagler Business School MBA@UNC ESCP Business School
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1 Comment -
Sanjay Shetty, MD
Medication adherence is critical to seniors’ overall health and well-being, including reducing the risk of cognitive decline. This article from our CenterWell Home Health team details how our occupational therapists partner with seniors and their caregivers with tips and tools to improve medication management and get patients back to their everyday routines. https://lnkd.in/eEKbmpsv #CenterWell #CenterWellHomeHealth
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2 Comments -
Chris Miller
Looking to improve patient outcomes and boost revenue? Aylo Health in Metro Atlanta implemented a Chronic Care Management program with ChartSpan, resulting in increased preventative care for Medicare patients, generating new revenue annually, and empowering patients with resources and remote care coordination. If you're interested in learning more about Aylo's success with a CCM partner, check out their free case study here: https://lnkd.in/eE-7wV29 and then lets talk. #healthcare #chroniccaremanagement #ccm #patientcare #casestudy
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Sam Holliday
Robin Goldsmith thanks so much for having Sameer Berry, MD, MBA on your show to talk about Oshi Health and our innovative care for #digestivehealth conditions. Such a great conversation around the challenges in #gastroenterology and how new care models like ours address them in ways that are a win for all stakeholders. #valuebasedcare #accountablecare #wholepersoncare
10
1 Comment -
William Sarraille
#340b Issues Left All Kinds of Fuzzy in the #IRA Draft Guidance Rich Daly’s 340B Report article charts a course through the 340B aspects of the “Year 2” #CMS #Medicare “fair price” guidance. I’m quoted. As Rich’s article explains, the guidance leaves stakeholders with more questions than answers. The article, which is definitively worth a read, makes the following 3 points: 1) There’s no provision for reliably identifying 340B duplicates. The use of 340B identifiers is “voluntary”, meaning that the #MTF data won’t be able to serve as a meaningful “screen” for 340B duplicates. 2) 340B #coveredentities, #contractpharmacies, and other #pharmacies are deeply concerned about the lack of details explaining how they will be paid the “fair price” by manufacturers. Well, manufacturers are equally concerned—in part because of CMS’s repeated threats, sprinkled throughout the guidance document, to subject #drug makers to #enforcement if their payments are inaccurate or untimely. The guidance’s vague and ill-formed provisions increase the enforcement risk, exponentially. 3) The guidance is marred by the agency’s lack of understanding of how distribution and data flows currently operate—and what can and needs to change to effectuate “fair price”. Ignorance and naïveté never lead to clear, dependable guidance. Implications: #Drug makers, if they have not already done so, need to partner ASAP with a contractor to do what the MTF won’t be capable of doing. You can’t rely on the MTF, and you don’t have much time to implement your own solution. One last note: I’ve expressed concerns about the timeline to get the MTF stood up. Comments to this proposed guidance are due July 2. Realistically, to review those comments and to address the gaping holes in the draft guidance, we may not get final guidance until October or November. After that, an RFP and contracting process would follow. This could mean that work would not begin, in a meaningful way, until November or December, with the holidays in full swing. That means just about a year, maybe less, of actual work time to get an MTF designed, implemented, and tested. I’m not saying that’s impossible, but it sure ain’t going to be easy. https://lnkd.in/eXvd2J-X
8
2 Comments -
Christopher Loumeau, MHA
"MA carriers and healthcare providers are reckoning with the effects of an updated fed policy governing IP hospital reimbursement. The 'two-midnight rule,' newly applied to MA this year, lets hospitals categorize more patient visits as higher-cost, IP stays. Providers and carriers are divided, however, as to it's early impacts on their bottom line. Here’s what you need to know: 𝗪𝗵𝗮𝘁 𝗶𝘀 𝘁𝗵𝗲 𝘁𝘄𝗼-𝗺𝗶𝗱𝗻𝗶𝗴𝗵𝘁 𝗿𝘂𝗹𝗲? The two-midnight rule (2013) states that FFS Medicare must pay for an IP stay if admitting clinicians anticipate patients will remain in the hospital for at least 'two midnights.' Now, MA carriers must also follow the rule. CMS said it wanted to align coverage guidelines b/w FFS Medicare and MA. But Unlike FFS Medicare, MA carriers don't have to automatically assume clinicians’ two-midnight guidance was appropriate and can use prior auth, internal coverage criteria or retroactive audits of claims when deciding appropriate reimbursement 𝗪𝗵𝗮𝘁 𝗔𝗿𝗲 𝗠𝗔 𝗖𝗮𝗿𝗿𝗶𝗲𝗿𝘀 𝗦𝗮𝘆𝗶𝗻𝗴? Some MA carriers have pointed to the two-midnight rule as a factor in driving up utilization costs. Humana, Aetna, a CVS Health Company and agilon health have all recently cited the two-midnight requirements as pushing the # of short IP stays in hospitals higher than pre-pandemic levels. Humana said this week that the rule will drive 'incremental pressure' on company earnings in 2024 and that they anticipate the rule will account for 0.5% of its 2024 medical expenses. UHG's UnitedHealthcare has not publicly mentioned any financial impact from the two-midnight rule. On its Q1 earnings call, it said MA members' costs this year weren't higher than expected 𝗛𝗼𝘄 𝗖𝗼𝘂𝗹𝗱 𝘁𝗵𝗶𝘀 𝗔𝗳𝗳𝗲𝗰𝘁 𝗛𝗼𝘀𝗽𝗶𝘁𝗮𝗹𝘀? The rule as applied to FFS Medicare was enacted in fiscal 2014 in response to concerns hospitals were improperly billing obs stays and IP visits. Hospital bills for short IP stays dropped by ~33% the year after the rule was enacted. The OIG plans to release another audit of providers' bills this year and recommend hospitals pay CMS back for claims improperly categorized as IP stays, rather than OP or obs visits. The MA version of the rule, however, could have a different result. The AMA publicized a report Mon from Strata Decision Technology that found the two-midnight rule contributed to higher IP visits in March. 22% of MA patients’ 2023 obs stays would be billed at a higher, IP rate this year under the new version of the rule. In March, hospitals’ IP revenue outpaced OP revenue for the first time since 2021 For-profit providers have had mixed reactions so far. Former HCA Healthcare CFO Bill Rutherford told investors in Q1 that they anticipate the rule update will provide a modest 2024 boost to the hospital chain. Altho execs from UHS and Community Health Systems reported a rise in IP and OP utilization and a rise in revenue per patient stay, they said they were seeing no benefit from the two-midnight change specifically"
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Michelle O'Brien
I find it curious to watch this trend happening in Australia a few years after the US as our retailers, pharmacists, PHI’s and single disease platform as a service models think Telehealth is the new gold rush. Australia has a much smaller population and a consumer that is far more likely to spend $600 having their dogs teeth cleaned than investing in their own chronic health management because we grew accustomed to having a good healthcare system .Our attempt to get universal health care right with some passionate governments who wanted to deliver fair and equitable health had us all believing that healthcare should be free and that is the mindset of the health consumer these new entrants think they can disrupt. We have a relativly new government with the same vision waking up to the cost of not investing in prevention and early intervention and programs that deliver health equity so hopefully we will see some investment from them now so care is not further fragmented. Will we see all this hype of healthcare is the new gold so everyone jump on board and cash in fizzle out the same way we are seeing it happen in the US now? #disruption
11
3 Comments -
Minalkumar Patel
If you’re a payer grappling with the best ways to manage care and costs as utilization rises and reimbursements slow, you will gain a lot of useful insights in a few short minutes with this video discussion I have with Mohamed Diab, MD, President of CVS Accountable Care. Dr. Diab brings unparalleled population health experience, supporting 70,000+ providers and 1 million attributed lives in Medicare risk-sharing models in rural, suburban and urban geographies across the United States. One key takeaway: It takes more and better data, especially social determinants, to build complete pictures of patients that are essential to delivering higher-quality care at lower costs. What’s more, it takes all of us, Dr. Diab says, to tackle this fundamental roadblock to transforming healthcare. “We definitely are not where we want to be as an industry when it comes to our healthcare data,” he told me. “It’s not easy but everyone needs to speak up about the need for better data.” Please tune into this new Abacus Insights Health Planning video Powering Accountable Care with Better Data and Analytics. It will be worth your while.
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Nathan Larson
🔍Is your behavioral health treatment strategy reactive or proactive? Starting May 7th, providers and patients can proactively measure treatment and gain insights into symptom severity with our new Behavioral Vital Signs™ report. As a provider, you'll get a comprehensive PDF report via secure message or right in your EHR. This includes trends for clinically validated surveys, actionable self-report data, and even intelligent passive sensing insights for the last 30 days. As a patient you will receive the same report in the Health Rhythms app, where you can share it with your wider care team and securely review them month over month. It's time to improve our mental health measurement capabilities to enhance treatment strategies and improve outcomes. #DigitalHealth #MentalHealthCare #HealthcareInnovation #PatientCare #healthrhythms #bvs #behavioralvitalsigns
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3 Comments -
Dr. Mohamed Diab, MBA
It was a pleasure to talk with Minalkumar Patel about the distinct needs of ACOs and where we see the biggest opportunities to optimize data to benefit patient health and provider success. I am delighted to share our conversation and look forward to much continued discussion on this important area of innovation for our industry. #valuebasedcare #aco #healthtech
60
2 Comments -
Nathan (N8) Kaufman
CVS' Oak Street Health to open clinics at retail pharmacies - those that do not learn from history are doomed to repeat it 1) There is very little evidence that, in recent years, a stand-alone primary care business will do anything but generate deficits. 2) The days of MA generating windfalls for PCPs are numbered due to recent premium reductions and regulatory oversight over the rampant abuses relating to Risk Scoring, PBMs, Prior Authorization, etc. Also, providers are refusing to contract with MA plans given their yield of 80-90% of Medicare and the overhead cost of dealing with denials, delays, and down coding, thus threatening network adequacy. Hospitals report they are frustrated with select CVS-affiliated MA plans taking up to four days to authorize transfers to nursing homes, requiring the hospital to absorb the cost of "unnecessary" days. 3) EBITDA must come from somewhere: a) better commercial contracts (not likely,) b) improved efficiencies (not in a large corporation,) MA risk (see above), an ASC (not for PCPs) and/or reduced physician compensation (highly probable.) This business model has not been sustainable in the past - what is different this time? We have seen this movie before. So it goes n8 #hospitals #healthsystems #medicareadvantage #primarycare #valuebasedcare
115
19 Comments -
Matthew Rechin
As revenues recover, it's clear that many hospitals are still grappling with rising costs. However, the hospitals that stand out are those embracing technology to drive efficiency and operational improvements, significantly reducing staff burnout. 🌟 Healthcare professionals entered this great profession to care for patients, not to be bogged down with manual tasks. That's why leading hospital systems are implementing comprehensive applications to enhance people, processes, and automation. This approach ensures cost-effective, top-of-license performance, ultimately benefiting both staff and patients. 💼❤️💡🔧 #GetReady #HealthcareInnovation #TechInHealthcare #OperationalExcellence #PatientCare
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Michael Macdonnell
Health care spending in the US is projected to have grown 7.5 percent in 2023, much faster than the nominal GDP growth rate of 6.1 percent, according to the wonks at CMS. About 17.6% of the share of the nation’s economy is now devoted to health spending or about $4.8 trillion. The entire GDP if the UK is about 2.3 trillion pounds or just shy of 3 trillion dollars. https://lnkd.in/eg_yK8yK
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Max Anfilofyev
The recent downsizing of VBC operations by giants like Walmart, Walgreens, and CVS marks a pivotal moment in the healthcare sector. This shift from a previous era of aggressive expansion to a more measured approach in scaling value-based care (VBC) reflects a maturing market that prioritizes sustainable growth over size. However, the contraction of these clinics doesn't signal a decrease in the viability of VBC models. In fact, top-performing Accountable Care Organizations (ACOs) continue to prove the profitability of focusing on primary care. These ACOs excel by strategically targeting practices that manage sick yet stable patients—those who are most manageable within a VBC framework and are crucial for consistent shared savings. The success formula is clear: select practices with the right patient demographics and ensure alignment with local specialists and hospitals ready to embrace collaborative, value-driven care. Maximizing risk scores and focusing on preventing care cost escalations in these targeted patient populations are essential tactics. As we move forward, let's consider these shifts as strategic realignments rather than setbacks. For those of us dedicated to transforming healthcare, it's a reminder to remain adaptable, data-driven, and patient-centered in our approaches.
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Nicole R. Braley
In the face of ongoing challenges, such as the recent shortages of FDA-approved GLP-1 medications (eg, Ozempic, etc), compounding pharmacies like Empower Pharmacy are stepping up to fill critical gaps. 💪 Our compounded medications are not only tailored to meet individual needs like allergies and dosage adjustments but also ensure that patients continue to receive essential treatments without interruption. Also, compounded medications are way more affordable. 💰 We're committed to personalizing healthcare solutions. By providing alternative forms and custom dosages, we make sure that everyone has access to the medications they need, exactly how they need them. Learn more about what we do --> https://lnkd.in/g_XRaHcM If you want to chat about it, DM me! #medicationshortage #healthcareinnovations #GLP1s #weightloss #diabetes #healthcaresolutions #houston #integrativehealth #access
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1 Comment -
Ken K.
Is your PBM truly working for your benefit? Too often, PBMs manage numbers to their advantage, leaving clients with suboptimal savings. It's time to demand more from your pharmacy benefits partner. At DisclosedRx, we believe that loyalty should lie with the client, not just the contract. We go above and beyond to ensure that you receive the best possible outcomes, not just the bare minimum. Don't settle for a PBM that prioritizes its own interests. Choose a partner that puts your needs first and consistently delivers the results you deserve. Ready to experience the DisclosedRx difference? Connect with us on LinkedIn today to learn how we can help you unlock the full potential of your pharmacy benefits strategy. #FullyDisclosedPBM #DisclosedRx #FiduciaryPBM
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1 Comment
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