Anders Gilberg

The Association of Healthcare Value Analysis Professionals (AHVAP) celebrates Elizabeth Eisenberg, MSN, RN, CVAHP from Scripps Health for commitment to excellence in the specialty of healthcare value analysis! Liz has signified this commitment by signing the official Association of Healthcare Value Analysis Professionals (AHVAP) healthcare value analysis pledge. To learn more about the Association of Healthcare Value Analysis Professionals (AHVAP) Commitment pledge: https://lnkd.in/gqEWPBue. #AHVAP #valuebasedcare #excellenceincare #valueanalysis

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Another section of the #FinalRule has been released by #CMS aimed at enhancing #access to and #transparency of #Medicaid services, including #HCBS. This rule pairs with two other final rules published in April 2024 that focus on improving Medicaid #eligibility and access to Medicaid services. This rule is focused on an #FFS system, but the impact could involve changes to underlying FFS rates in base #data for #ratesetting and program #oversight in #MLTSS. Dianne Heffron and Meredith Mayer of Mercer US Government have conducted a review of the proposed and finalized rules. https://bit.ly/3QuGRXe

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#SDPSeptember kicks off with the release of our new brief, “Better Care Access and Outcomes with Medicaid State Directed Payments.” Learn more about how #EssentialHospitals are using state directed payments (SDPs) to improve care in communities. https://bit.ly/47t3sdN

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Check out this informative brief from America's Essential Hospitals (AEH) explaining the vital role State Directed Payments play in increasing access to care and improving #healthcare quality nationwide. We applaud the impact that is being driven by these programs and our clients. Click AEH's post below for the full brief. #SDPSeptember #EssentialHospitals #healthcare And click this link to explore more insights from Sellers Dorsey on improving healthcare quality and access: https://hubs.li/Q02Q70Bf0

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Following the end of the COVID-19 public health emergency and Medicaid continuous coverage, many states have routed people who have lost Medicaid benefits to the Affordable Care Act (ACA) Marketplace. In the July issue of Health Affairs, Mark Meiselbach and colleagues at Johns Hopkins University explore county-level overlap in carriers and networks in Medicaid managed care and the Marketplace in 2021. They find significant variation in “the share of Medicaid managed care beneficiaries covered by carriers that offered ACA individual Marketplace plans in their county in 2021.” Also, on average, 52.1 percent of Medicaid managed care enrollees were enrolled by a carrier that also had a plan on the Marketplace in the same county.” Read the full paper: https://bit.ly/3Sw0LlA

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Carefully consider this proposal and tie through related to VBP transitions and AI tools.

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I’m thankful that I could share my thoughts at that very hearing. There is so much misinformation about 340B. For me, it comes down to two main points: 1- if hospitals need that money as a subsidy to fund everyday activities, they should just ask for a subsidy. Let’s open up the books of these institutions, which already get a huge subsidy with their non-profit status, and see why they are running in the red. Are they really losing money on Medicaid patients or are they just bloated and inefficient? 2- let the subsidy follow the patient. This is a drug benefit program. Why does the funding go to an institution? Imagine if we did that with SNAP, giving a bunch of money to large restaurant chains in exchange for their promise to use the revenue to provide food for poor people (with no oversight to ensure that’s done). We don’t do that; instead we give the benefit to the person who needs it. Let’s change 340B to match that model. Adam J. Bruggeman, MD, MHA, FAAOS, FAOA Daniel Choi Colin Yokanovich John Strom Peter Stein Adam Fein Deborah Williams Lisa Grabert Maya Babu, MD, MBA Katie Orrico Larry Bucshon, M.D. Ann M. Richardson, MBA

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Exciting news! The Connecting to Coverage Coalition, of which AMCHP is a member, has published a comprehensive policy paper on improving #Medicaid and #CHIP eligibility determinations beyond the unwinding of the COVID-era continuous coverage requirements. As we navigate the unwinding period post-pandemic, it's crucial to ensure eligible individuals, including children and pregnant people, retain their coverage. Read the coalition's recommendations and join the conversation on how to support better healthcare outcomes for all: bit.ly/CCCunwinding

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Yesterday, COGR submitted a letter in response to the Centers for Medicare & Medicaid Services (CMS) RFI on Research Data Request and Access Policy Changes.   The current CMS system permits researchers to obtain physical data extracts of CMS Research Identifiable File data (“RIF Data”) for use on institutional systems that meet CMS-prescribed data security standards. CMS has proposed changes that would prohibit the release of physical data, and instead require researchers to solely access RIF Data via CMS’ Chronic Conditions Warehouse Virtual Research Data Center (CCW VRDC).    This would harm important health-related research.   COGR’s response highlights how the proposed changes would severely curtail researchers’ ability to link RIF Data with other data sets and use the wide variety of analytical tools that are available at their institutions. These changes would impede both on-going federally funded research and the development of new research projects that are vital to improving patient outcomes and lowering healthcare costs.    COGR’s response also expresses strong concerns about proposed steep increases in fees that researchers will be required to pay to access the CCW VRDC. These increases will pose a substantial cost burden for all institutions and especially harm the ability of emerging research institutions and early-stage researchers to conduct research using CMS data.    Bottom Line: COGR urges CMS to reconsider the proposed changes and instead permit continued access to physical data while working with the research community, as necessary, to explore alternate mechanisms to address data security concerns. COGR Letter: https://lnkd.in/eRu6Mu27 CMS Request for Information: https://lnkd.in/egPMCyQE

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New for 2025, CMS is rolling out a geographically based targeting option for Medicare Advantage organizations based on an Area Deprivation Index. If these orgs get things right, this could mean opportunities with new enrollees (especially in Midwest and Southern states) with potential rewards, incentives, and reduced cost sharing. This is in addition to CMS’ 2025 proposal to draw from ACO REACH and its geographic adjustments (which saw some big winners). If finalized, savvy ACOs would have additional capabilities through prepaid shared savings. tl;dr, CMS continues to push geographic considerations for beneficiaries. #sdoh #healthequity #medicare #medicaid .Variate Health

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Epic Systems’ recent move to back the TEFCA medical records exchange is interesting. On the surface, it’s all about creating a seamless flow of patient data across hospitals, QHINs, and all relevant stakeholders. But let’s be real—data is the oil of the new economy, and interoperability is the pipeline that delivers this precious resource to all the right stakeholders. By aligning with TEFCA, Epic might just be positioning itself as the refinery. All in all, this is a welcoming move by Epic Systems—especially if it really is as straightforward as they make it sound. But given the lack of details, one has to wonder if there are any hidden catches. After all, when it comes to something as valuable as healthcare data, it’s wise to look out for the fine print. Let’s hope this is genuinely about improving patient care. https://lnkd.in/gDdDCcmj

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🚨 Telehealth Access at Risk 🚨 What we at the American Telemedicine Association and ATA Action thought was good news—a two-year extension of Medicare telehealth flexibilities, first-dollar HDHP-HSA coverage, a five-year extension of Acute Hospital Care at Home and the Diabetes Prevention Program in the Continuing Resolution—is now in jeopardy. Broader political dynamics are threatening this vital funding package. Millions of Americans rely on these provisions for their care. Without action, access to telehealth services and innovative virtual care programs could expire on January 1, 2025. We’re working tirelessly with Congress and stakeholders to ensure these critical measures are protected. The stakes could not be higher. Your voice matters—reach out to your representatives now to urge them to prioritize telehealth in any funding package. Let’s make sure patients, providers, and our healthcare system don’t lose the progress we’ve fought so hard to achieve. #Telehealth #HealthcareAccess #ATAAction Read more:

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How can #Medicaid policymakers advance the adoption of value-based arrangements by Federally Qualified Health Centers? 1.     Through the Return of Shared Savings to #FQHCS. – Participating FQHC networks should be eligible to share in a substantial portion (50% or more) of the savings realized when the actual total costs incurred for their attributed population are below the benchmark or goal set for average Total Cost Of Care (TCOC). 2.     Adjust the Payment Model for the FQHC Patient Population. – The benchmark costs used to set rates should be based on the average #TCOC in the market, or the average amount the Managed Care Organization gets paid per enrollee, rather than using the FQHC networks’ own historical low reimbursement as a starting point. Learn more in this report authored by our Kim Prendergast, Aditya Mahalingam-Dhingra, and Vikki Wachino for the Milbank Memorial Fund - https://lnkd.in/eCGMECd2 #Valuebasedcare ##FQHC #ACO #TCOC #Medicare #ProspectivePaymentSystem #ManagedCare #Managedcareorganizations #VBP #Healthcarequality #CMS #healthequity #Communityhealthcenters #Communityhealth Massachusetts League of Community Health Centers National Association of Community Health Centers (NACHC)

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Big Win for Telehealth Providers! I’m thrilled to share a significant victory for Medicare providers delivering telehealth care, thanks to the latest CY 2025 CMS Physician Fee Schedule (PFS) proposal. The Centers for Medicare & Medicaid Services (CMS) has proposed to extend the flexibility allowing distant site practitioners to use their currently enrolled practice location instead of their home address through 2025. The American Telemedicine Association and ATA Action have been at the forefront of this important issue, urging for this crucial reprieve to support Medicare providers. This provision addresses critical compliance and security concerns associated with divulging home addresses. This step forward not only ensures the safety and privacy of healthcare providers but also reinforces our commitment to advancing telehealth services for Medicare beneficiaries. Here's to hoping this flexibility becomes a permanent fixture, safeguarding our dedicated practitioners and enhancing patient care. #Telehealth #Medicare #HealthcareInnovation #CMS #ATAAction #ProviderPrivacy #HealthcareCompliance Find out more:

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On December 19, CMS released additional guidance to states on compliance expectations for providing Medicaid and CHIP services for incarcerated youth. Gini Morgan and I wrote up a quick summary of the takeaways for State Health and Value Strategies here: https://lnkd.in/e6ZVYyx8

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#healthcon 2024 @aapc. Last breakout session on Observation Care and Condition did not disappoint. Key takeaway: Hospitals changing the patient’s status during observation to inpatient should be robust in their documentation for the change to inpatient status. This is important for compliance with utilizition review when CMS and state Medicaid agencies are ramping up their #RAC #audits

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My Friday good news celebrates the heroes of value-based care: primary care physicians and teams. The most successful #Medicare ACOs, those delivering value for Medicare and Medicare beneficiaries and sharing in that value, are primary care-centric #ACOs. We know how they do it; the playbook often includes support from enablers like Aledade, Inc.. Dr. Menard and his colleagues didn't give up when success wasn't immediate. How do we grow more primary care-centric ACOs and generate more value for Medicare and more access and quality care for beneficiaries? There are some health system ACOs investing in primary care and integrated teams. But it might take more forceful nudges from Medicare to get big health systems participating in total cost-of-care risk models. Or, we might need payment policies to give primary care more independence to practice comprehensive care. Congress could also consider restructuring the APM bonus to reward primary care "centricity". #primarycare #valuebasedcare Primary Care Collaborative David Raths David Muhlestein AAFP Foundation Thomas Culhane, MD, MMM, MS Darrin Menard, M.D. Stacey Richter https://lnkd.in/dThMvJrQ

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The Centers for Medicare & Medicaid Services released its annual health spending assessment in Health Affairs, revealing concerning trends: - Medicare spending is spiraling out of control with little political will to reduce costs. - Health spending is projected to reach 20% of GDP soon, outpacing wage growth and decreasing affordability. - Private healthcare costs grow slower than government spending, emphasizing the importance of private coverage. COVID and IRA policy are major drivers of these issues: - Post-COVID pent-up demand is increasing costs across hospitals and doctors. - Prices and aging are having a major impact as well. - Medicare spending is expected to grow significantly, reaching historic rates, putting pressure on taxpayers. - Unsustainable cost growth is looming, with the average family projected to spend 40% of their income on healthcare within five years. Transformative changes in Medicare policies are crucial for long-term sustainability: - Using the successful Part D model in Medicare Advantage and fee-for-service. Part D leverages competition and incentives hold down costs. - Deploying new (and real) incentives to deliver value should be incorporated while reducing regulatory/reporting burdens on providers. Fee-for-service is uncoordinated and drives waste and overutilization of services that may harm patients. - Addressing $51 billion in annual Medicare improper payments (fraud) and ensuring payments structures are vital. The program's trajectory towards $2 trillion in 2032 demands thoughtful planning and strategic reforms to ensure the program's future viability and alleviate the burden on taxpayers. Learn more about the assessment here: https://lnkd.in/etpJWRdr Council for Affordable Health Coverage

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