Dean Jargo

As a health system, should you expand geographically or focus on service line specialities? Or both? These are the types of questions we help hospitals and health systems answer. HSG Advisors partners with healthcare leaders to identify opportunities for profitable top line growth through data- and experienced-informed strategies. #healthcareconsulting #HSGStrategy #hospital #healthsystem #healthcareleader #revenue

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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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Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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Recent projections from Jefferies indicate a significant shake-up for insurers: - Humana: Faces the largest hit, with an expected $2.5 billion reduction in EBITDA and a staggering $16.37 EPS drop, marking an 83% decline compared to 2025 projections. - UnitedHealthcare: Set to lose $1.6 billion in EBITDA, alongside a $1.39 EPS decline (4%). - CVS/Aetna: A relatively modest gain of $100 million in EBITDA and a $0.05 EPS bump (1%). - Elevance: A $100 million reduction in EBITDA with a $0.30 EPS decline (1%). - Centene: A positive outlier, expected to increase EBITDA by $100 million and boost EPS by $0.10 (1%).

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Drex DeFord Advises Simplifying Healthcare for Vendor Risk Reduction: https://lnkd.in/dDvhYsDF First Health Strategic Advisory Board Member & Healthcare Strategist Drex DeFord dives into pressing concerns around the increasingly complex, difficult to manage, and frequently targeted healthcare environment. Drex’s conversations with This Week Health fuel meaningful conversations to spur the change necessary for improving health sector resilience. We’re proud to have such a dedicated member of the healthcare cybersecurity space advising our leaders and ensuring First Health is at the forefront of digital health security innovation. For more insight into First Health’s leadership and board members, visit https://lnkd.in/gQUx5BzD or contact First Health at [email protected]. #CISO #CIO #CTO #CDO #Compliance #HIPAA #HealthcareIT #HealthcareSecurity #CyberRisk #ThirdPartyRisk #RiskAssessment #Cybersecurity #HTM #DigitalHealth #PatientSafety

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How Medicare Advantage is Benefiting Medicare Fee-for-Service The debate between Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) often focuses on their distinct benefits: FFS offers flexibility and broad provider access, while MA emphasizes care coordination, preventive care, and supplemental benefits. However, what is often overlooked is how Medicare Advantage has influenced Medicare FFS, driving important innovations and reshaping healthcare for all beneficiaries. Medicare Advantage: A Catalyst for Value-Based Care MA plans operate under a value-based care model, incentivizing providers to prioritize outcomes over volume. They identify high-quality, low-cost providers, monitor referral patterns, and reduce hospital readmissions. MA addresses social determinants of health with benefits like transportation and meal delivery, ensuring beneficiaries receive coordinated care. Medicare FFS Adopts Value-Based Practices Traditionally, Medicare FFS reimbursed providers based on the service volume, leaving beneficiaries to self-refer and manage their care. Influenced by MA, FFS is evolving through: • Accountable Care Organizations (ACOs) and the Shared Savings Program, incentivizing care coordination and chronic condition management. • Expanded preventive care benefits, like wellness visits and screenings, encouraging beneficiaries to actively participate in their health. Improving Outcomes Across Medicare MA’s focus on care coordination and quality improvement has proven effective, with: • Lower readmission rates • Better management of chronic conditions Meanwhile, FFS is making progress by adopting similar practices, though challenges remain. Many FFS beneficiaries still rely on episodic care rather than comprehensive management, and providers face a cultural shift to align with value-based principles. Challenges and Opportunities • MA plans: Strong care coordination but may have narrow networks and require prior authorizations, limiting specialized care. • FFS: Broader provider access but lacks MA’s systemic incentives to improve outcomes and lower costs. Conclusion The innovations pioneered by Medicare Advantage—proactive care, provider accountability, and a focus on wellness—are influencing Medicare Fee-for-Service, helping shift it from a reactive, “use-it-when-you-need-it” model to one that prioritizes prevention and care management. Together, these programs are creating a future where all Medicare beneficiaries receive better, more holistic care—no matter their chosen path. 💡 Let’s continue the conversation: How can Medicare FFS and MA work together to create greater benefits for all? Share your thoughts below! #Medicare #HealthcareInnovation #ValueBasedCare #Healthcare #Medicareadvantage #Medicareforall #Healthcareplans

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Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

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Planning for Medicare - Countdown to 65 Please join Medicare expert and Senior Plan Consultant at Blue Cross Blue Shield of Massachusetts, Susan Flanagan for this lively discussion about Medicare.  Topics Include: •  Medicare and Medicare Parts A and B •  Medicare enrollment timeline •  Medigap plans that supplement Medicare coverage •  Medicare Advantage plans, such as HMOs and PPOs •  Medicare Part D prescription drug plans •  Plans and programs available to early retirees, such as COBRA

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With over 2 million members displaced by major healthcare players exiting underperforming Medicare Advantage markets, regional insurers face both a challenge and an opportunity. This influx of high-cost members demands innovative solutions to manage chronic conditions like diabetes and heart failure effectively. At Circadian Health, we’re helping regional insurers navigate this disruption with virtual-first specialty care, reducing costs and improving outcomes for the most complex members. This market shake-up isn’t just a challenge—it’s a chance to redefine care delivery. Discover how regional insurers can transform disruption into opportunity—read more on our blog. #MedicareAdvantage #HealthcareInnovation #VirtualCare #CircadianHealth #ValueBasedCare #HealthEquity

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The Great Reckoning in Medicare Advantage: Collaboration or Division? The landscape of Medicare Advantage is facing its biggest shift in two decades, according to McKinsey, which is presenting new challenges for payers and providers alike. As pressures mount, the vital question emerges: “How can health systems avoid getting the smallest slice of the remaining pie?” In a recent panel of payer and health system executives hosted by Strategy Catalyst, executives from both sectors discussed the future. The consensus? Those positioned to thrive in the impending Medicare Advantage "great reckoning" will be the innovators who foster collaborative efforts to optimize each other's cost structures. What might this entail? • Payers could seek to reduce their own cost-regulating denials and prior authorizations by trying to work collaboratively, focusing on efficient data sharing and solution-driven dialogues with providers. • Providers could streamline contracts to only work with those seeking mutual value, guided by well-defined principles for selecting partners and governing contract performance. Potential collaborative areas: • Jointly deciding on supplemental benefits that will be high impact of the population and promoting their utilization through the health system's medical group. • Establishing joint quality measures that would allow movement to prospective payment systems. • Exploring evidence-based care guidelines that could be agreed upon jointly to reduce administrative burdens, like unnecessary prior authorizations. Join the conversation and let us know your thoughts. For more detailed insights, ask for our two-pager on the future of Medicare Advantage.

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Let's explore the critical factors shaping the landscape of MA STARs ratings in the upcoming year with a focus on quality and excellence. 🌟💊 🏥 🩺 2025 Medicare Advantage and Part D Star Ratings: Key Metrics for Providers ⭐ 💹 https://lnkd.in/e7aZkZvC Introduction to Star Ratings: -> Star Ratings measure the quality of health and prescription drug services for Medicare enrollees. -> CMS aims to improve the quality of Medicare Advantage (MA) and Part D programs. Significant Metrics for 2025: - Part C Plan All-Cause Readmissions -> Increased weight from 1 to 3, emphasizing the importance of reducing hospital readmissions for comprehensive care. - Tukey Outlier Deletion: -> Applied to improve the accuracy of measure-level cut points used to determine star ratings. -> Aims to minimize the influence of extreme outliers on performance measures. Performance Measurement: -> Contracts rated on up to 40 unique quality measures for MA-PD contracts and 12 for PDP contracts. -> Cut Points: Established thresholds to determine rating (1-5 stars) based on performance. Year-over-Year Rating Trends: -> Changes in measure-level cut points for 2025 reflect a shift towards higher performance standards. Example Metrics: -> Breast Cancer Screening (Part C) -> Average star rating decreased from 3.9 (2022) to 3.4 (2025). -> Colorectal Cancer Screening (Part C) -> Similar downward trend, indicating a need for improvement in preventive care measures. Impact of Contract Experience: -> Contracts with 10+ years in the program tend to achieve higher star ratings, highlighting the importance of experience and stability in delivering quality care. Tax Status Influence: -> Non-profit organizations typically achieve higher ratings (50% earning 4+ stars) compared to for-profit counterparts (36%). Consistency in High Performance: -> Contracts consistently rated with high performance icons (5 stars) maintain strong service delivery, with many having special needs plans (D-SNP). Conclusion: Providers should focus on improving metrics like all-cause readmissions, refining methodologies for accurate performance measurement, and maintaining consistent care quality to achieve higher star ratings in 2025 and beyond.

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Shifting the financial model alone is not sufficient for the transition - the care delivery, workforce, and many other pieces of the ecosystem with which PCPs interact also need to adjust accordingly. Funding to allow for the startup costs of transformation must be made available. A comprehensive analysis from The Commonwealth Fund: To encourage participation, practitioners say upfront payments, investment in the primary care workforce, and less emphasis on simplistic quality measures are needed, as well as more support for practices to provide accessible, comprehensive care. #primarycare #integratedcare #teambasedcare #healthcare #healthcareonlinkedin

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"Rarely have the pathologies of the Medicare Physician Fee Schedule portended such poor outcomes for the future of U.S. healthcare as they do now." In a new Healthcare Financial Management Association (HFMA) blog, APG President and CEO Susan Dentzer describes the four main flaws in the Medicare Physician Fee Schedule. "Those of us hoping for a better system for paying physicians should keep pushing for alternative payment models." #valuebasedcare #Medicare #healthcarecosts Read the blog: https://lnkd.in/dGVE8dfM

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The pressure of ongoing litigation compels payers to reimburse providers fairly for their services, even beyond IDR. This is vital in the current #healthcareindustry landscape, as the strain on provider and payer relationships is at an all-time high. The AHA’s 2022 survey found that 78% of hospitals believe their relationships with #healthinsurers are getting worse. With contract negotiation disputes increasing almost 70% between 2022 and 2023, it is challenging for providers to get insurers to comply with contracts that will keep their practices alive. Allia Group’s healthcare #litigationfinance platform offers an opportunity for enhanced negotiation leverage, as pressure from an outside organization helps providers negotiate favorable terms to potentially return in-network or enter for the first time. Learn how legal finance is transforming provider #reimbursement strategy by reading our blog. Find the link in the comments section.

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Is your practice losing money due to billing errors? Our team can help optimize your revenue cycle, so every claim counts. #RevenueOptimization #HealthcareBilling #MedicalBillingHelp #HassleFreeClaims #urgentcare #primarycare #hospitalbilling #physicianbilling #medicalbilling #hcfacode #hcfacoderror #cptcode #insuranceaccepted #claims #medicalclaims #deniedclaim #clearinghouse #clearinghouseaccepted #erapayerdenial #denails #claimdenails #RCM

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