Brian C Smith

This is quite incredible to see. Very few #CMMI demonstrations can point to any savings at all. And “…MSSP savings go further than savings generated by Medicare Advantage…” #ACO #VBP #Primarycare #MSSP #healthcareinnovation

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Despite the "less conclusive quality and cost findings" shown by Hospital-at-home AHCAH programs for Medicare, participants in the program (both patients and clinicians) give it a thumbs-up. Big proponent of moving appropriate acute/post-acute care into the homes, however, a lot of these programs were not well executed and many were not appropriately resourced. It's not surprising that the overall data on quality and cost is underwhelming. Hopefully, the 2 yr extension (currently legislation due) should allow for this picture to become clearer. #HaH #AHCAH #Hospitalathome #Homehealth

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Radiologists are achieving payments 500% above the Qualified Payment Amount (QPA) in surprise billing disputes, thanks to the No Surprises Act. This figure is staggering and highlights an important reality: many providers might not realize the tremendous potential of this opportunity. When the No Surprises Act (NSA) was enacted in 2022, the rates at which providers were reimbursed took a major hit, often cut in half. Payors exploited the QPA to justify lower payments, essentially giving themselves the green light to underpay claims. If a provider disagreed with the payment, they had to navigate the cumbersome claims process to recover what they deserved. But here’s the good news: By participating in the IDR process, radiologists are claiming up to 5 times their initial payments. This result is a powerful incentive for payers to engage in a meaningful negotiation and ensure fair compensation. Providers should leverage the NSA to their advantage - and capture every dollar they’re owed.

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A whirlwind of activity last week at the America's Physician Groups conference. Lots of solid insights shared by health system leaders. Some notable thoughts: +++ Artificial intelligence is intelligent in different ways: By now, we all know ai has a diverse set of use cases, incorporated in different applications and tools. But there are fundamental differences in how the intelligence itself is brought to life. Examples include: - Predictive AI, used to forecast future outcomes by leveraging historical data. Shout out to UCLA’s CKD/ESRD early intervention protocol (Joycee Berin) and Diagnostic Robotics’ intelligence care post-dicharge journeys (Kira Radinsky) - Protocolized AI, used to automating a user’s administrative load by using a set of detailed, pre-defined rule sets. Thanks to ARC for sharing their experience using Elaborate 's automated outpatient lab summaries (Manish Naik) - Generative AI, used to create new content. Great overview of ambient documentation at MGB as well as Cedars’ Sinai talking through its medical ontology model powering acute triage (Caroline Goldzweig) Across system leaders and experts, there was clear agreement that the first step to implementing intelligence intelligently is defining the ‘jobs to be done’. That way, internal and external stakeholders are clear on what they're solving for when they architect the solution.  +++ Scaling AI takes time and rigorous observation: Market leaders describe a phased pilot approach that allows clinicians to build confidence and system leaders to measure ROI before deploying systemwide. Loved hearing Rebecca Mishuris outline MGB’s novel approach of piloting two solutions against one another, to pressure test implementation, workflow, and value creation. +++ Proving ROI continues to be challenging: Lots of vendors using lots of different metrics to prove value, but the majority of leaders agreed that estimating the ROI of these new tools today is part science, part art. Demonstrating the ROI of the “soft” metrics around provider burnout and retention seemed to be a big opportunity, especially for investment in more efficient primary care and PCP wellbeing. After all, PCPs drive referrals to specialty-level care (and higher reimbursements) for health systems. Appreciated Anurang Revri's overview of how working team setup can also impact ROI estimates. +++ Value-based care = tools + humanity: VBC will require not only implementing tools to support clinical documentation, risk capture, upcoding, etc, but also humanizing interactions to engage patients. Countless examples, but one that made me smile was a depression focused chat bot responding in the following interaction: - Context: post-discharge check in Bot: Hi Freida, how are you feeling today after your surgery?  Patient: I’m having a tough time, am in a lot of pain.  Bot: Well, it can’t be that bad, I’m sure it will get better with a positive mindset!    🤣 🤣 🤣 Can't wait for next go-around!

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Should you sell your practice to a VC-Backed MSO Startup? tldr: - new VC-backed startups are forming MSOs to roll up independent practices - The pitch is physicians receive early liquidity from the roll up and are granted ESOP shares that can be used for retirement - Problem is the use of ESOPs with independent practices is not a new concept and has been used with large group practices since the 70's - ESOPs do not grant full ownership and in order for the shares to be valuable for retirement, the practice needs to run the same if not better post roll up - With VC-backed startups being primarily operated by non-physicians with zero clinical or medical practice experience, the likelihood of this happening is extremely low making the entire concept high risk However, there is a viable path for continued ownership + liquidity for independent practices. Check out the article to learn more. ⤵ https://lnkd.in/gmGvTYwP

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Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

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Weekly lessons learned - Where did that $200 Billion of acute care revenue go? Hospital C-suites, Carter Williams and I did quick math >$200 BILLION in acute I/P revenue will evaporate if just 25% of those w/1 chronic condition take a GLP-1 and 50% of those avoid 1 hospitalization. This aligns w/Yubin Park, PhD recent data on ACR which would only add to this estimate. And hims & hers is showing this revenue shift real time with a 70% YOY increase Matthew Holt. Even 23andMe is making a comeback play w/Lemonaid Health (part of 23andMe) Sergei Polevikov, ABD, MBA, MS, MA 🇮🇱🇺🇦 Sticking w/"meanwhile an entirely new healthcare ecosystem is being built and we are still focused on heads in beds" 🙄 Superpower and Max Marchione went live with their beta and a video that liteally compares him to Steve Jobs, Bill Gates, Elon Musk and Jeff Bezos in 0:38 sec., well alrighty then. As of now it's a marketplace w/diagnostic testing akin to Function Health (on steroids) comingsoon. Josh Erndt-Marino 😉 One of my favorites Michael Muntner at Crestview Partners announced Cardinal Health has added a GI MSO and Advanced Diabetes Supply to its portfolio 😉 Thatch Chris Ellis is partnering with Quickbooks (hello 1 million small businesses) to bring ICHRA to the masses, hope POTUS doesn't kill it - Brad O’Neill Brendan Keeler was on fire pointing out that AI is actually live on Epic, TEFCA vetting process update and a substack piece for the ages chronically Epic's battle scars and brokedown AI w/impacts, Patrick McGill, MD MBA calls copilots a game changer and Christina Farr added to this by asking - Is AI "time savings" going to mean doctors and care teams get more time with their existing patients than the 6m visit? or have to do more... When will we learn our bricks and mortar lesson?! Forward Health literally imploded in a matter of months after burning $100M largely on pods Guy Culpepper, MD In food news 🥕 Dear health systems you have better choices than Sodexo! Matriark Foods (Anna Hammond) is now a Vizient, Inc #environmentallypreferredsupplier - you can impact your Scope 3 emissions goals AND provide healthy delicious foods to patients 🥑 If you don't know Clancy Harrison and The Food Dignity Movement you should If Robert F. Kennedy can steer clear of reversing vaccines, maybe he really can help "Making America Healthy" - #foodishealth vs. #pharmaisking. Graham Walker, MD Andy Mychkovsky Erin W. Martin Billy Wynne did a great piece in Health Affairs about what the election could mean for HC and Andrew Schwab continues to share great post election intel and Sachin H. Jain, MD, MBA weighed in on MA impacts For my next rabbit hole this week - the report for Accountable Health Communities Model is out Darshak Sanghavi along w/2023 ACO REACH 2023 results next week. $1.6B program savings results which Chris Deacon pointed out could in fact be losses via evaluation findings - I'm conflicted - after working with so many ACOs I know they create true value.

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Let's keep hospice focused first and foremost on the PATIENT. After all, we only get one chance to do it right... "There are six primary trends that are influencing consolidation and professional practices: regulatory complexity. technology and integration, private equity ownership. demographics, economies of scale and consumer expectations,” Henderson said. “So many of these things that we see that are influencing health care consolidation need to be pointing toward the patient." #patientsfirst #hospicecare #youonlygetoneshot https://lnkd.in/gbbgV-YF

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Blue Health Intelligence, a data analytics and software company, undertook an evaluation of almost 170,000 unique GLP-1 users for weight loss, notes less than half of those prescribed stay on the medication for 12 weeks or more. Younger adults were less likely to continue the drug, whereas those who were prescribed the medication by an endocrinologist or obesity medicine specialist were more likely to continue for longer. Indeed, this data states 30% of patients dropped out of treatment after the first four weeks, and 58% at 12 weeks. Those who dropped out are unlikely to achieve clinically meaningful weight loss.  The likelihood of continuance was further exacerbated for those with health inequities or who lived in underserved health regions. The data comes from Blue Cross Blue Shield Association members participating in Plans that provided coverage of these products, from 2014 through to end of 2023. Razia Hashmi, vice president for clinical affairs at Blue Cross Blue Shield wants to ‘…paint a clearer picture of what makes somebody successful.’ The missing piece here is why the patients stopped – side effects, failure to achieve initial weight loss, stigma and discrimination, or coverage issues related to cost and access. My longtime friend, colleague and bariatric surgeon at Stanford University, Dr. Dan Azagury rightly states ‘…The goal is for patients to stay on this for a significant amount of time. Most likely… beyond 12 weeks.’ https://lnkd.in/ediQskQx

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The US Physician Workforce will be decimated by the boomer doctor retirement cliff between now and 2030. A disturbing pattern in recent study findings makes this issue much more urgent - and the timeline to impact much shorter - than the government predictions. Let me show you why. The new statistics, the references ... everything The dots will all line up when you watch this short video and I'm happy to have the chance to show them to you. If you are a physician leader, this video is a Must-Watch because the mainstream media is not covering this phenomenon. Employers are only focused on short-term results: the numbers at the end of this second quarter, or the end of 2024.  They don't see this long-term trend. I also strongly recommend you share these videos with your C-suite - especially if your organization does not have a Corporate Wellness Strategy in place at this time. Learn what to watch out for - and what you must start doing now - to implement a Physician Wellness Strategy while there's still time. This trend will play out over the next three or four years. It's inevitable. You can't fight father time and nobody's getting any younger. Every doctor needs to know what is coming. Watch these short outtakes from this week's Wellness Champion Summit Webinar https://lnkd.in/gFYckWS4 **You will learn** 👉 What is the Boomer Doc retirement cliff? 👉🏽 How bad is it? 👉🏿 Recent changes in female physician and medical student behavior make things much worse. 👉 How the answer to this one question to your CMO doubles the projected physician shortage of 2030. 👉 Does AI at the same time make things better or worse? 👉🏿 What your organization must do now to prepare. 👉🏽 Why I'm predicting a brief window of opportunity for a corporate Physician Wellness Strategy - but you must act now!

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Wow thanks Graham Walker, MD for highlighting this Podcast with Mark Cuban. I have to say when I first learned of Mark Cuban when he became owner of the Dallas Mavericks, I thought he was another billionaire with only self interests and looking for the national spot light. Through the years, he has positively changed my mind. First with his move into making medications more affordable with @costplusdrugcompany (https://lnkd.in/gXHjh9NR) and the move to eliminate pharmacy benefit managers (https://lnkd.in/gXgRqj_2). In the pharmacy realm, he really has been getting work done: CureMatch, Inc.: Cuban's company has collaborated with CureMatch to promote affordable cancer treatment. CureMatch received an AMA CPT® Code for its Algorithmic Cancer Therapy Ranking Service. He has worked with Select Health to lower prescription drug costs. He has laid out details about how he's disrupting drug pricing see, American Hospital Association (https://lnkd.in/gu_xECn5) And since with his provocative takes on healthcare spending such as this one in Forbes (https://lnkd.in/gj-7YiXE). Now this Podcast where in the span of 30 seconds explains a major reason for high healthcare costs -- hospitals and doctors are subprime lenders and since insurance companies need to spend 85% of their annual revenue on healthcare costs-- they only have one way to go--UP. Interesting. I never thought I would say this but--- maybe the U.S. needs a dot.com era billionaire, NBA owner to lead disruption of the U.S. sick care system. #UsingWhatWeHaveBetter Thoughts? Is Cuban right? on the right track? Jeff Helton, PhD, CMA, CFE, FHFMA, David Keller, Jesse Ehrenfeld MD MPH, Sachin H. Jain, MD, MBA, Larissa May, MD, MSPH, MBA, Scott J. Campbell MD, MPH, Erik Pearson, MD FACS, Umbereen S. Nehal, MD, MPH, MBA, Thomas Campanella, Ge Bai, Alyssa Abo, MD, MBA, Arlen Meyers, MD, MBA, Ann M. Richardson, MBA, J. Michael Connors MD, Mary Beth Miotto, MD, MPH,

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California Bill Would Require State Review of Private Equity Deals in Healthcare — Consumer advocates and labor unions are enthusiastic about the plans, but hospitals are not A bill pending in California's legislature to ratchet up oversight of private equity investments in healthcare is receiving enthusiastic backing from consumer advocates, labor unions, and the California Medical Association, but drawing heavy fire from hospitals concerned about losing a potential funding source. Hopefully, more states will initiate the same approach to keeping close tabs on private equity buying healthcare-related entities. Private equity firms raise money from institutional investors such as pension funds and typically acquire companies they believe can be run more profitably. Then they look to boost earnings and sell the assets for multiples of what they paid for them Critics say the profit-first approach isn't good for healthcare. Look to Stewart Health Care where the CEO and C suite lined their pockets while driving the health system into the ground. "Almost all of the most distressed U.S. healthcare companies are owned by private equity firms." Time to rein in private equity vultures out there in healthcare trying to make a quick profit, raising the costs of healthcare in their quest to generate profits. #privateequity, #runningthehospitalintotheground, #vulturecapitalist, #forprofithealthcare https://lnkd.in/ea3pFz43

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Understanding the distinct perspectives and strategies of providers and payers is crucial for effective negotiation and risk management. These insights can help providers and payers avoid common pitfalls, as well as highlight the importance of alignment between them. Looking forward to more insights from you and your team Joseph Rafferty. Teaming up with Michael McCabe is a smart move.

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🤔 How do (US) hospitals spend money 101? Salaries, Wages, Benefits: 45-55% Professional Services: 12-22% Supplies: 12-18% Depreciation/Amortization: 3-6% Other Expenses: 5-20% 8 key insights: n°1. Hospitals consume 31% of US healthcare spending: Despite being the largest spending category, many hospitals struggle with low operating margins, often below 2%. n°2. Labor costs dominate hospital expenses: Salaries, wages, and benefits account for 45-55% of a hospital’s expenditures, with front-line staff making up 75-82% of the workforce. n°3. Contract labor adds significant costs: Hospitals often resort to staffing agencies due to labor shortages, paying 2-3 times more for contract workers compared to employed staff. n°4. Supplies account for 12-18% of expenses: This includes medical equipment, drugs, and personal protective equipment. n°5. For-profit vs. non-profit hospitals: For-profit hospitals tend to manage costs more efficiently, keeping salaries and expenses lower, but often at the expense of services like Medicaid or charity care. n°6. Economies of scale in larger health systems: Larger systems benefit from negotiating better prices for supplies and services. n°7. Rural hospitals face unique challenges: Limited access to talent and capital means rural hospitals must rely more heavily on expensive outsourced labor and struggle to offer high-margin services. n°8. Staffing shortages remain a key issue: Despite financial recovery post-COVID for many hospitals, staffing shortages continue, driving hospitals to explore different revenue models and operational changes to sustain profitability.​ Great post by the Out-Of-Pocket team Nikhil Krishnan & Ben Chao #healthcare

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For all the talk about value-based care, progress still is very slow. Advisory Board data shows the small amount of progress made from 2017 to 2022, which varies drastically by line of business. Medicare Advantage is the primary segment driving VBC, mainly due to aligned incentives where plans and providers could get paid more through upcoding (or "appropriate coding") of patients to drive more revenue & margin through the entire system. That drove penetration of VBC in MA, and CMS has paid attention, releasing significant headwinds (v28, RADV, Stars) aimed at reducing these perceived overpayments. In other segments, VBC has been very slow to grow. Commercial VBC arrangements were essentially stagnant. Anecdotally, this is starting to change. Plan sponsors (employers) -- especially large, sophisticated ones -- are demanding more from their carriers. They want to see network arrangements that impact quality & cost. Will that be enough to drive VBC activity in the commercial space? We'll see. Employers -- the customers -- will be the ones who will drive VBC forward here. TPAs alone don't have the incentive to make changes. I remain hopeful, but skeptical. #valuebasedcare #healthtech #digitalhealth

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