Elizabeth Simpkin

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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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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Self-directed Medicaid home care models have the potential to produce better patient outcomes and satisfaction than agency-directed models, and warrant further study, the Medicaid and CHIP Payment Advisory Commission (MACPAC) said Thursday during its December meeting.

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OIG ALERT: Diagnoses reported only on enrollees’ HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023. Before we dive in here I want to say that I have seen HRAs used appropriately and inappropriately during my time in this space. There can be great value for patients, particularly those with limited access to care and or those reluctant to visit their primary care provider. However there is tremendous risk to the system if these visits are a fragmented approach to care and or not aligned with care planning. What the OIG has identified represents the risks and shows care continuity breakdowns. Ultimately organizations and payers must know their vendor partners because there are some really good ones in this space. Earlier this week the OIG released a really interesting look into Health Risk Assessment, or HRAs. These HRAs are often performed in the home by payers or vendor partners. These should be in depth reviews of the patient and include a host of assessments that often are hard to complete in a condensed visit to a provider office. What the OIG found was that 7.5B or about 2% of all Medicare revenue was tied to conditions captured only during these visits. Is that bad? I don’t know. If these are new conditions and then ultimately incorporated into a broader care plan that improves outcomes then they are a great thing. If they are captured, never shared with the care team, and ultimately used to solely drive revenue with little focus on outcomes then it is bad. I suspect there is a mix of both. If I was at the OIG I would want to take a multi-year look at what was captured year over year only in a HRA as a next step. The report recommends CMS take the following actions. CMS subsequently agreed with recommendation number three but not numbers one and two. 1) Impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments. 2) Conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews. 3) Determine whether select health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies. I am doing some advanced analytics on information in the report for future posts but this is a nice easy read for folks. https://lnkd.in/ehNzzSWu

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Economic forces and political rhetoric mean that uncertainty will continue to plague key hospital revenue streams. These conditions may not be surprising but are certainly exhausting for clinicians, #HTM teams, and #CapitalPlanning committees. Looking inward for strategies to increase the availability and output of equipment resources can help health systems build stability in clinical operations. Becker's Healthcare https://hubs.ly/Q030ljJl0 

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Join this upcoming webinar from The Better Care Playbook on 11/22, 12–1:15pm ET, which will spotlight three state Medicaid agencies (CA, IA, and TN) that are a part of the Medicare Academy — an initiative which provides Medicaid and partner agencies with training to build Medicare knowledge needed to successfully advance integration goals. The state panelists will address how they are establishing and sustaining Medicare capacity. The event will also feature a dual-eligible enrollee who will share considerations for improving Medicare and Medicaid coordination to help enrollees navigate these programs. https://bit.ly/40yJwF7 The SCAN Foundation, Arnold Ventures, The Commonwealth Fund, California Department of Health Care Services, Iowa Department of Health and Human Services, TennCare

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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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🆕 Pediatric Resource for Working with Private Insurance! Pediatric Concurrent Care: Advocating for Private Insurance Coverage, a new toolkit for NHPCO members, will help inform providers about how to work with private insurance companies to advocate for coverage of concurrent care for pediatric patients. Through this toolkit, hospice staff will learn how to discuss the importance of concurrent care with insurers, how to set expectations with families, the language insurers may use, and examples of working with private insurance companies. Download the toolkit here: https://lnkd.in/gpCu_y4i

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Check out this quick and insightful review of the latest updates from CMS, brought to you by the #Michigan Health & #Hospital Association (MHA)! 🚑📊 The proposed #Medicare 2025 Outpatient Prospective Payment System rule includes a net 2.3% increase, new service additions, the adoption of three measures related to health equity and more: https://lnkd.in/gS8rTHEr #HealthcareUpdates #CMS #Medicare2025 #MHA #OPPS

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HEALTH CARE TRANSFORMATION SUMMIT: June 10-11 Explore the present and future of health care at our Inaugural Health Care Transformation Summit. This will be a comprehensive gathering of Indiana’s largest health care stakeholders to foster ideas and solutions to improve health care outcomes, increase access, and decrease costs for patients, providers and employers. Attendees will gain perspective on the short- and long-term evolution of the health care industry, including the impacts on today’s workplace. This is a unique opportunity to understand where we are today and where we’re going in the future. Panel topics include: - Employer Strategies - Obesity in the Workplace - Ensuring Access to Pharmacy Benefits and Supply Chain Security - Innovative Models of Health Care - Rural Health Care and the Role of Hospitals in the Future of Health Care - Role of Insurance Companies in the Future of Health Care - Emerging Models and Technology in Health Care - Price Transparency - Preventative Care and Precision Medications Presented by CVS Health. Register: https://lnkd.in/gAkVkDQ4 #healthcare #healthcaretransformation #healthcaresummit

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HEALTH CARE TRANSFORMATION SUMMIT: June 10-11 Explore the present and future of health care at our Inaugural Health Care Transformation Summit. This will be a comprehensive gathering of Indiana’s largest health care stakeholders to foster ideas and solutions to improve health care outcomes, increase access, and decrease costs for patients, providers and employers. Attendees will gain perspective on the short- and long-term evolution of the health care industry, including the impacts on today’s workplace. This is a unique opportunity to understand where we are today and where we’re going in the future. Panel topics include: - Employer Strategies - Obesity in the Workplace - Ensuring Access to Pharmacy Benefits and Supply Chain Security - Innovative Models of Health Care - Rural Health Care and the Role of Hospitals in the Future of Health Care - Role of Insurance Companies in the Future of Health Care - Emerging Models and Technology in Health Care - Price Transparency - Preventative Care and Precision Medications Presented by CVS Health. Register: https://lnkd.in/g7CesAPv #healthcare #healthcaretransformation

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Health literacy is vital for advancing Medicaid equity. Center for Health Care Strategies latest resource equips healthcare professionals with practical strategies to improve how they communicate with Medicaid members, ensuring patients understand and access the care they deserve. Strengthening these communication efforts helps break down barriers, fosters trust, and leads to more equitable health outcomes. Explore these insights to enhance patient engagement and drive better results in your community.

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Healthcare has made improvements but there's still a long way to go to become truly digital-first. While we've seen advancements in telemedicine, electronic health records, and AI-driven diagnostics, the journey to fully integrate these technologies into everyday practice is far from complete. And the “door” to care – patient navigation – needs a lot of work. If we don't evolve, patient's will find others who do! https://lnkd.in/eSJKiHSR #patientcentricity #digitalfirst #digitaltransformation #patientnavigation

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New #valuebasedcare partnership slated to transform care delivery for Medicare populations by integrating @Lumeris’ technology solutions with @CarleHealth’s clinical expertise. #qualitycare #populationhealth

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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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A very nice article highlighting and summarizing 'real world' insights and strategies for success in #MedicareAdvantage by leading healthcare organizations, including Henry Ford Health. Worth the read!

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Cost analysis in isolation lacks depth. Consider comparing costs - or cash shortfalls - from multiple angles: -Procedure codes -CPT codes -Payers -Aged A/R A record of CARCs and RARCs can be used to map shortfalls and denials, getting you closer to the root causes. This is what my team calls an RCM Health Check and I’m covering the concept in a webinar this Thursday. Join me here: https://lnkd.in/epuhRSn7 

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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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Medicare's proposed updates to labor market areas could have a significant impact on hospitals' rural and urban status. Check out this article for an in-depth analysis on the labor market delineations: https://ow.ly/pfJj50RhxoU...

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