Allyson Keller

I'm thrilled to share a recent article from the Spring 2024 Winship Magazine highlighting the incredible efforts of our team in addressing oncology drug shortages. This challenge is a critical aspect of patient care that often goes unnoticed but requires immense hard work, coordination, and planning. A huge shoutout to our exceptional pharmacy department, especially our pharmacy technicians, buyers, and inventory teams. Your dedication ensures that our patients have uninterrupted access to the vital medications they need for their unique cancer treatments. Kudos to our Medical Director, Dr. Jonathan Kaufman for his leadership and unwavering commitment to overcoming these challenges. Throughout this process the integration between our physician and pharmacy leadership has been outstanding. The relentless efforts behind the scenes by our Winship Cancer Institute of Emory University teams are pivotal in providing top-notch care to our patients. It's a humble reminder of the intricate work that goes into each patient's journey, making a significant difference in their fight against cancer. To everyone involved in making this possible—thank you for your remarkable work! Read the full article to learn more about how our teams are making strides in mitigating oncology drug shortages: https://lnkd.in/exrXHFQ9 #PatientCare #Oncology #PharmacyHeroes #TeamWork #CancerCare #EmoryHealthcare #Winship #Cancer #Healthcare #Drugshortages #shortages #Medicationshortages #LifeSciences

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Huntsville Hospital Health System, a 14-hospital network in Alabama and Tennessee, is terminating its contract with UnitedHealthcare, impacting both commercial and Medicare Advantage plans. The health system cited UnitedHealthcare’s high denial rate, which is 75% higher than other insurers, as a primary reason for the split. Despite ongoing efforts for over a year to negotiate a mutually beneficial contract, Huntsville claims its proposals have not been reciprocated by UnitedHealthcare. The termination will affect Helen Keller Hospital on Oct. 15, with other hospitals exiting UnitedHealthcare’s network through 2024 and 2025. UnitedHealthcare countered that Huntsville is requesting a more than 25% price increase, despite already charging nearly 20% more than the average hospital in northern Alabama. UnitedHealthcare remains open to further negotiations. This dispute highlights a broader trend of increased contract disputes between payers and providers, with such conflicts rising 69% between 2022 and 2023. Other systems, like Duke University Health System, have also reported higher claim denials by UnitedHealthcare. Our RCM team assists healthcare systems in navigating payer contract disputes by providing expert analysis of denial rates, negotiating terms, and identifying opportunities for resolution. We help ensure accurate claims processing and optimize revenue recovery, ultimately improving payer-provider relations and maintaining financial stability during contract transitions. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Becker's Healthcare

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Today marks an important milestone with Emory Healthcare’s announcement of their statewide PHC and collaboration with Guidehealth. We began our commercial relationship with Emory Healthcare Network earlier this year on an interim basis and quickly progressed by fully integrating our technology and capabilities. In a short time, our joint efforts have created “speed to value”, demonstrating considerable traction and early wins on quality, patient care and overall performance. There are many people to thank - - and I'll start by acknowledging the network and service line leadership of Patrick Hammond, Tina-Ann Kerr Thompson, MD, MBA and their teams including Dan Salinas, MD and Susan Helton, Adam Tribbett and many others. Unless they saw the merits of us working together, we wouldn’t be here. We as a company have grown through inspiring engagement with Emory’s digital health leadership led by Alistair Erskine MD MBA and his team including Nitu Kashyap. The data science architecture, our use of AI and integration into Emory’s digital health strategy has transformed our business in many ways including accuracy and risk prediction, clinical prioritization, outreach and access, and scalable interventions. A shout out to Guidehealth's technology partners who have led us to unprecedented success and first mover advantage of our platform. I want to personally acknowledge Joon S Lee MD, Emory Healthcare CEO for his vision and personal attention to our collaboration. As also Chris Augostini, EVP and Emory University CFO. Their teams have been working closely with us to make today’s announcement a reality. Finally, to our leadership, at every level beginning with MARK SELNA, McKay Crowley, MD, MBA, FACP, CHCQM, Robert Alterman, Michael Gleeson, Roger Ou, Jeanne Wisniewski, ACC and their teams who’ve been working tirelessly to integrate technology and people into partner workflows, I want you to know that none of this would have been possible without your creativity, dedication and higher purpose that you bring to bear for patients and physicians every day. With today’s announcement, we now support six health systems in four states across a variety of contracts. With Emory, our collaboration extends across all patients and payers and is by far the most comprehensive and clinically integrated expansion of our model. And with it, we are honored to firmly plant our flag in the Peach State! https://lnkd.in/eARfUMnG

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I would venture to say that our Clinical Documentation Integrity (CDI) team at Pediatric Resource Group (PRG) has more collective years of pediatric CDI experience than all other CDI consulting firms combined. 110 years amongst us and we are not done growing our team. If we include my physician advisor consultants that support peds CDI, the years of experience goes beyond 150. It's not just experience. Our team is full of national CDI leaders who speak at conferences regularly as well as CDI and coding leaders at major children's hospitals. We bring that expertise to our clients to assess, develop or optimize pediatric and neonatal CDI programs around the country. Peds is different from a care, culture, and reimbursement perspective. Your CDI consulting partner needs to understand all the nuances associated with this unique patient population. Hospital leaders, let's connect to see how PRG can help you optimize or cover peds/NICU CDI. CDI consultants, let's partner on peds clients. Amy Bush, BS, RN, MJ, CCDS, CCS, Kristen Johnston Jorde Spitler MHA BSN RN CCDS, Ashley Ezell, Kristin K., Kesia St Romain, Amy Philen, BSN, RN, CCDS, Jeff Morris, BSN, RN, CCDS, CCS, Jessica Audino-Iwuji #pediatricCDI #clinicaldocumentation #peds

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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

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🚨 Update on Baptist Health and Florida Blue Negotiations 🚨 Negotiations between Baptist Health and Florida Blue are ongoing and remain tense as the September 30 contract deadline approaches. Discussions have been underway since February 2024, but no agreement has been reached. The core issue is payment rates: Baptist Health seeks increases to cover rising costs, arguing that current rates are below market, while Florida Blue contends that these demands are excessive and significantly above inflation. With the potential for Baptist Health services to become out-of-network for Florida Blue members on October 1, many patients in Northeast Florida are left uncertain about their healthcare options. Both sides are committed to finding a resolution, but time is running out. 🔗 Sources: Action News Jax, Baptist Health, Health News Florida

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💡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!

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Sharing key takeaways on the CMS Hospital Inpatient Quality Reporting program for FY2025. - Seven new measures are added (which are welcome, with the caveat of let's see how they work out) -> Patient Safety Structural Measure beginning CY 2025 with payment determination in FY 2027 -> Age Friendly Hospital CY 2025/FY 2027 -> Catheter-Associated Urinary Tract Infection Standardized Infection Ratio Stratified for Oncology Locations (CAUTI- Onc) CY 2026/FY 2028 -> Central Line-Associated Bloodstream Infection Standardized Infection Ratio Stratified for Oncology Locations (CLABSI-Onc) CY 2026/FY 2028 -> Hospital Harm – Falls with Injury (eCQM) CY 2026/FY 2028 -> Hospital Harm – Postoperative Respiratory Failure (eCQM) CY 2026/FY 2028 -> Thirty-day Risk-Standardized Death Rate Among Surgical Inpatients with Complications July 1, 2023–June 30, 2025/ FY 2027 - Five existing measures are removed (which is a breath of fresh air) - the unpopular PSI-04, and measures related to 30-day episode payments for acute myocardial infarction, pneumonia, total hip/ knee arthroplasty, heart failure - Two existing measures are modified (Global malnutrition composite score expanded from seniors over 65 to anyone older than 18 - this is very positive; and Refined HCAHPS measure - will post details on this next week.)

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🔥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

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As announced in the CMS Proposed Rule for CY 2025 Outpatient Prospective Payment System released in July 2024, the ON-Q device is proposed for approval under the NOPAIN Act and to receive a unique code eligible for separate payment effective January 2025. This would mark the first time that the ON-Q® device would qualify for separate payment. Learn about NOPAIN: https://ow.ly/T9NQ30sHjnm #PainManagement #NOPAINAct

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Price, payment, and cost. Their confusing relationship is healthcare is a major contributor to the complexity of care delivery. List price, assuming you can find it, often differs wildly from one provider, facility, or health system to the next. Part of the game is that (almost) no one pays list price, it's an inflated number used as a negotiating tool. Provider payments, which also vary widely based on who's paying, are often significantly less than list price. Patient payments are equally confusing. Deductibles, co-pays, co-insurances, networks -- and so on. On top of it all are various principle-agent problems and moral hazards. Another quirk of healthcare, prices and payments are not as strongly tied to costs as they are in many other industries -- in part because few fully understand what the costs are. It's often hard to square direct costs (the unit cost of taking care of a single patient or doing a particular procedure) with indirect costs (keeping the doors open, the lights on, and employees paid). Not to mention "indirect direct" costs which lead to cost shifting. The more inefficient, complex, and bloated care delivery becomes, the harder it is to measure and control costs (especially indirect ones). To bend the cost curve, you must find it first. Simplifying the relationship between price, payments, and costs will go a long way to resolving these issues. Prices should be transparent and consistent. Payments should be fair and tied to value. Indirect costs can be controlled through creating efficient, reproducible processes, leveraging technology, and sound business models. Managing direct costs requires economies of scale, adherence to evidence-based practices, and constant measurement and iteration. Maybe the fundamental problem isn't that we treat healthcare like a business, it's that we treat it like a poorly run business. #healthcare #health #medicine #valuebasedcare #vbc #healthcareinnovation #transparency #healthtech #healthcaretechnology

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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

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And there we have it! Tonight, many of us with pour over the 2025 Proposed Rule for the PFS. For 15+ straight years, the proposed rule includes a cut to the conversion factor, and we are possibly looking at a 6th straight year that some, or all, of that cut makes it into the Final Rule. For 15+ years, we have all written letters and signed petitions to end up in the same place with no real change in the slanted budget neutrality rule and actual recognition of the Medicare Economic Index. With 92% of healthcare providers continuing to see heavy increases in operating costs (MGMA), this isn't an equation that works, and it is going to break. Real change comes when the real problems are confronted, and we are a decade beyond having that conversation. #medicare #healthcarefinance

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Key Strategic Insights = A Successful OP CDI Program The challenge of value-based care starts with a collaborative approach, when launching an Outpatient Clinical Documentation Integrity (OP CDI) program. Here are some key strategic insights to success: 1. Engage with Population Health Understand Pain Points: Begin by understanding the specific challenges faced. This fosters collaboration. Tailored Questions: Use customized questions to facilitate productive discussions and ensure alignment with needs. 2. Effective Software Implementation Manage Patient (Pt.) Volumes: Implement software solutions to efficiently handle pt. volumes. OP CDI Calculator: Utilize a calculator to determine Full-Time Equivalent (FTE) needs. Data Analytics and Reporting: Emphasize the importance of continuous improvement via data analytics. 3. Workflow Creation Establish Robust Workflows: Create strong workflows before integrating reviewers. 4. Collaboration & Communication Promote Strong Collaboration: Encourage robust communication between key stakeholders. Leverage Software: Use technology to reduce physician burnout & streamline communication. 5. Patient-Centered Approach Address social determinants of health (SDOH) & ensure accurate documentation of conditions and care plans. Patient Outcomes: Keep patient care at the center of all doc. & workflow processes. 6. Regulatory Compliance Adhere to Guidelines: Follow regulatory requirements such as CMS guidelines on Hierarchical Condition Categories (HCC) coding to avoid penalties and enhance credibility. 7. Measurable Outcomes Set Clear Goals: Aim for measurable outcomes like improved HCC recapture rates, enhanced RAF scores, better HEDIS measures, and addressing SDOH needs. 8. Stakeholder Engagement Involve All Stakeholders: Ensure that executives, clinicians, and other relevant parties are involved in planning and implementation process. Success Stories Recently, I helped several CDI directors validate their cases for OP CDI programs within Accountable Care Organizations (ACOs). By engaging with population health leadership, we identified key issues such as RAF gaps and HEDIS measures, and tailored processes to address them. For instance, a CDI director I guided successfully identified HCC and HEDIS recapture as their biggest pain points. With strategic solutions in place, they are now ready to implement the project for the 2025 budget yr., aiming to improve their HCC recapture rate by 20%, leveraging data analytics for outcomes and improvement needs. Benefits of Implementing These Strategies Align Risk Stratification: Properly align risk stratification with chronic conditions and healthcare needs. Quality Measures: Improve quality measures and address SDOH. Collaborative Team: Ensure success with a collaborative team supported by technology. Overall, these strategic actions will enhance patient care and operational efficiency. #Healthcare #Leadership #CDI #PatientCare #ValueBasedCare #HealthcareInnovation

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Revenue cycle is a critical part of the patient journey for the provider. It's not just about spend, but about the top-line health of the hospital and performance management.

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1 in 5 physicians in North Carolina are contemplating suicide and not telling anyone. Why? They feel like a burden. As North Carolina Medical Board president Christine Khandelwal, DO, MHPE, FAAFP, FAAHPM noted, "physicians often feel they will become a burden to others if they admit to feeling depressed or hopeless." What is the message that physicians are receiving where they feel like a problem instead of part of the solution? How many meetings have I been in where a group of doctors was tagged as "resistant" or "unwilling to change?" I love being a doctor like so many of my colleagues. But I also hear how difficult it is to practice medicine these days. So many feel like they don't belong or their voice isn't heard. Why is that and what can we do to help? From the patient perspective, many believe that doctors are still in positions of power. That we can address the annoying phone trees or wait times to see us. But we can't. As Ann M. Richardson, MBA told me recently, 75% of physicians are employees now rather than practice owners. We have lost a seat at the table and it's killing us. For those who feel this way, you are important and you matter. I see your hard work and your care. If you are in North Carolina, please contact the North Carolina Physician's Health Program. I donate to this important work every year when I renew my license. https://ncphp.org/ #physician #employeewellness #burnout #mentalhealth #healthcare

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Check out the article by our awesome CEO!

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This ProPublica article on EviCore by Evernorth—a healthcare utilization management company making the yes/no care decisions for many health plans—highlights two glaring issues: 1️⃣ The Dial: Automated claim denials are illegal, but the workaround is adjusting thresholds for automated approvals (e.g., 95% or 75% likelihood of approval). #Claims falling below these thresholds face manual reviews, leading to delays and increased denials. 2️⃣ Risk Contracts: While provider risk contracts aim to incentivize better health outcomes, for utilization management (UM) companies, the financial incentive skews toward limiting claim payouts—not improving care. These practices don't exist in isolation. They involve multiple players—UM companies, health plans, employers, consultants, and more. I believe most people in these organizations genuinely want to improve healthcare, so where’s the cognitive dissonance? My thoughts: ☕ Drinking the Company Kool-Aid: We justify the system with phrases like “bending the cost curve” or “right care at the right time.” But let’s keep it simple: would I want my mother to experience this? Would I want to be the doctor on the other side? 💡 Fatalism and Incrementalism: We accept the system as unchangeable and focus on small improvements—like removing 15% of prior authorization requirements that never should have existed—rather than challenging the ethics of the system itself. So, what can we do? A few years ago, I recall a conversation with my friend, Bukata Hayes, MBA, where we discussed why we do this work. It’s not just about helping our companies better serve people—it’s also about being internal activists. Yes, change in healthcare requires some bold macro-policy shifts, but I think meaningful progress can start with us. How can we consistently use our influence to challenge the status quo and push for ethical, patient-centered change - be that internal health activist? What do you think?

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