Craig Solid, PhD

New study in #HSR from Yevgeniy Feyman PhD et al  measure specialty provider networks in Medicare Advantage (MA) and examine associations with market factors. WHAT IS KNOWN There is limited evidence on the relationship between MA network breadth among specialists and plan or market factors. WHAT THIS STUDY ADDS Using a recently developed algorithm for measuring the restrictiveness of primary care providers, this study measures the network restrictiveness of nine high-prescribing specialties among MA contracts. CONCLUSION Findings suggest that rural beneficiaries may face disproportionately reduced access in these networks and that efforts to improve access should vary by specialty. FULL ARTICLE: https://lnkd.in/gnn6Uwmk Wiley AcademyHealth #HSR 

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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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Are you prepared for the coming additions to The Centers for Medicare and Medicaid Services (CMS) Medicare Advantage (MA) Star Ratings Measures? Beginning January 1, 2025, CMS is implementing additions and changes that will impact 2027 Star Ratings. MA Plans and providers must ensure they are fully prepared to identify beneficiaries for which these new measures apply and develop strategies to address their care needs — and time is ticking. Learn more: https://lnkd.in/guWcY3w2 #FTIHealthcare Key Contacts: Mark Van Ert and Krunal Patel

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Introduction of Medicaid APM options for federally qualified health center (FQHCs) was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. https://ja.ma/4daDw8H

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Only UHC Has the Facts, Here are Guesstimates Based on the Data Available Assumptions Based on Data Submitted by UHC for 2023 per 215 ILCS 200/20 of the IL Prior Authorization Act ·         The only data independently reported is for UHC Commercially Insured State of Illinois (excludes ERISA Plans) ·        UHC fully insured 2022 commercial covered members in Illinois: 257,398 (from CMS MLR Database) ·        Total prior authorization requests for UHC commercial plans: 163,886 (.63/member/year) ·        Total “adverse determinations” (denials): 36,310 (22% of requests denied - 14 "adverse determinations" per 100 members) ·        Average time between submission and response: 4.52 calendar days (740,764 delay days) ·        Total appeal requests: 7,640 (21% of denials appealed) ·        Total appeals overturned (including partial overturns): 6,007 (79% of appeals are overturned) https://lnkd.in/gxsmFVr5 Extrapolation of UHC’s IL Reported Data to the Entire Population Enrolled in UHC’s Commercial Plans ·        UHC fully insured 2022 commercial covered members in the US: 6,890,422 (from CMS MLR Database) ·        Estimated fully insured and self-insured members in the US administered by UHC: 15,312,049 (assumes 45% of UHC administered members full risk is 45%) ·        Estimated prior authorization requests for UHC commercial plans: 9,749,223 (.63/member/year) ·        Estimated “adverse determinations” (denials): 2,160,005 (22% of requests denied) ·        Estimated appeal requests: 454,487 (21% of denials appealed) ·        Estimated appeals overturned (including partial overturns): 357,343 (79% of appeals are overturned) ·        Days of Treatment Delays for UHC’s Commercially Insured Members in the US: 44,066,487 delay days Check my math --- So it goes n8 #hospitals #healthinsurance #healthsystems #physicians

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Happy to share my new research showing that growth in #340B provider participation over the past decade was associated with a significant ($32 billion annually!) increase in overall per-enrollee Medicaid spending. The 340B program leads to distortions in provider behavior that appear to reverberate across the system. Read the full report to learn about the impact of 340B and the program’s cost to taxpayers: https://bit.ly/4c4p3dG 

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Interesting perspective on #TechnologicalDebt in health care by Dave Lamar focused on the provider market, but we seem the same issues within state depts and payers. While good data governance practices are key, there must be a better way to solve this common - if not universal - challenge in health care, if only by offloading some of the administrative responsibilities that require the individual management and administration of no-value-add administrative functions. #healthdata

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Loper and #Medicare #Reimbursement: What Does the Future Hold? Ganny A Belloni from Bloomberg News wades in (in a terrific article) on the implications of #Chevron and the rise of #Loper on Medicare reimbursement issues. I'm quoted. My take? I think, as I say in the article, Loper will have less impact than people think. Loper eliminates Chevron “deference” by a court to an agency’s interpretation of a federal statute, where that law is “ambiguous”, meaning it can reasonably be read in different ways. Congress can (and will) significantly reduce the risk of litigation challenges in a Looer world by, as Ganny summarizes the point, defining statutory terms more precisely and "more clearly and explicitly giv[ing] the agency the discretion to decide issues". Further, many potential challenges can be avoided by CMS, as I say in the article, by framing "more ... [agency] decisions as ‘factual determinations’ or ‘adjudicative’ questions, where it still is entitled to deference, even after Loper.” To those of you who are fans of the administrative state, take heart. The sky, truth be told, is not falling. #healthcare Centers for Medicare & Medicaid ServicesU.S. Department of Health and Human Services (HHS) #CMS #HHS #APA #administrativestate #agencydiscretion #rulemaking #agencies #administrativelaw

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Two new proposed rules could be a game changer for health data interoperability... In early July (published in Federal Register August 5), ASTP/ONC released all 1,067 pages of its proposed HTI-2 rule, in which it proposed expanding its Certification Program to complement CMS' FHIR APIs. This included creating criteria impacting payers and public health IT. It reminded me of a line of questioning from ONC's electronic prior authorization RFI from January 2022, where the agency asked nearly ten questions about what certification criteria should look like to facilitate electronic prior authorization processes. The thought then, and even at the publication of HTI-2, was that certified modules wouldn't help payers much because payers are not the ones implementing modules. The vendors who provide the administrative platforms are. As it stands, there are only disincentives to certifying under the program for payer health IT vendors (i.e., bringing them under the information blocking rule), so payers are really at the mercy of their vendors. This is in stark contrast to the impact the program has on EHR developers. That was until HHS' ASFR and ASTP/ONC released another proposed rule on August 9 that would require all providers and health plans (that means you, MA plans) that receive HHS funding to use certified health IT or adhere to ONC standards at a minimum. So, what does this mean? Payers who receive HHS funding could now have the regulatory support to require their vendors to be certified... If passed as written, payer health IT vendors that want to maintain their contracts with federally funded plans would not be able to "unreasonably limit" the exchange, access, or use of electronic health information - including charging an unreasonable fee. They could be penalized up to $1M per violation if they do. This is a huge deal. Luckily, the team at Maverick Health Policy summarized both proposals (linked below). If you need help navigating these changes, we're here to help. HTI-2: https://lnkd.in/g4McbwMy Acquisition Regulation: https://lnkd.in/gWY--VPb

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It seems that the government is serious about finally realizing the vision of true health data interoperability. The attached Point-of-Care Partners blog post describes the recently released HTI-2 Proposed Rule which is another step in the fruition of that vision. Point-of-Care Partners can help your healthcare organization stay ahead of the waves of regulatory activity around interoperability. Let me know if you are interested in learning how.

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A new #EBHC scoping review explores how health service and delivery systems in high-income countries define and operationalise #HealthEquity. 👉 https://ow.ly/ZxaY50ShGWU

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I’ve been given advice that the fastest way to monetize HER Heard without charging the end user (woman) is trackers and selling data. Instead, I’d like to build something more trustworthy. I don’t want to be in a headline like this. If you are not paying, then you are the product (you/your data are being sold). There are newer ways to deindentify data or even to aggregate things women search for that can be of interest to various stakeholders. In theory that could be okay to sell, but in a post-Roe world with laws encouraging bounty hunting, I am vetting the choices ahead. I am all for moving fast, without breaking things.

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https://lnkd.in/gjW7AhCs. All I can say looking at some of the drops in profits reported in this Becker's article is here come the CV audits to make up for the losses. Given enough time MA, IMO always seems to be a zero sum game with respect to network rate increases and the ability to audit post discharge based on the payer's own terms, often not defined under contract. Join Richelle Marting JD, MHSA,RHIA,CPC,CEMC,CPMA and me as we talk about this issue in an upcoming webinar on Wednesday, August 21st. https://lnkd.in/gJeSABDj

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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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Great commentary and details to be considered from post by Deborah Williams Too few probably understand what you've posted, the other major part of the problem. Commercial insured populations (employers & employees) pay the price for government policy failures that represent major hits on company bottom lines or lead to more individual bankruptcies today. #employeebenefits #employers #commerialinsurance #epcouncil.org

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There’s no question that AI is transforming healthcare, and understanding where industry leaders perceive opportunities is important. The latest research report from Arcadia is revealing. 63% of healthcare leaders say AI can analyze large patient data sets to identify trends and create population health intervention strategies 58% say AI can analyze individual patient data to identify opportunities to improve health outcomes 47% say AI can optimize the management and analysis of electronic health records Dive into the report to gain insights from top tech leaders and see where the industry is headed! https://lnkd.in/gf_wkWij

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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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Most viewed in the last 7 days from JAMA Health Forum: This JAMA Forum discusses the current data collection mechanisms used for Medicare and proposes ways to improve nationwide data collection efforts for Medicaid. https://ja.ma/4dJuqzJ

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