Geoffrey Rutledge

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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It's wild to think in 2024 we're FIRST seeing the DOJ accuse telemedicine conglomerates of criminal drug distribution. How long have we known about these practices in brick and mortar care...? Answer: decades! Take it from someone who prescribed stimulants and other psychotropics to kids over the years - painstakingly measuring and documenting the need and impact - these appalling abuses by Done and Cerebral mean we need more calls for thoughtful pause when it comes to working with startups. Particularly about funding's role - my favorite topic! 🤑 How did we end up with venture capital and PE financing in healthcare that risk the safety of kids in the name of exorbitant returns? Not that all VC or PE dollars are bad, of course, but they're certainly key drivers who shouldn't be in that seat. Did we underestimate these funders as 'barbarians at the gate', much like the pharma reps of the 90's and early 2000's heyday? Have we not learned from Purdue Pharma's aggressive and deadly Oxoycontin marketing? Purdue pleaded guilty to criminal charges and paid $600 million in fines in 2007. Or TAP Pharmaceutical Products's Lupron kickback scheme for the prostate cancer drug? TAP also pleaded guilty to criminal charges and paid $875 million in fines in 2001. Or Pfizer marketing Neurontin, an anti-seizure drug, for off-label uses, such as treating pain and bipolar disorder, even though the drug was not approved for these purposes, and paying physicians kickbacks. In 2004, Pfizer pleaded guilty to criminal charges and paid $430 million in fines. Cerebral and Done's playbooks were practically the same thing, just with a modern mid-pandemic, low-regulatory scrutiny, digital-platform twist. Will appropriate regulation ever outpace American venture greed? Is it even possible to ensure patient safety AHEAD of tragedies driven by the intersection of innovation and venture funding? If you're keeping score, healthcare regulatory reactivity: 1 million. Healthcare ounces of smartly preventive policy: 3. Blech. 😖 When will we finally own that prevention in-house? #healthcare #overdoseprevention #suicideprevention

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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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Rural health. Is the one we’re we need to see improvement not in care, but in operational efficiency. So nice to see implementation of AI methodologies. I have been a bit of a sceptic, AI tool tries to save physican and care provider time, but than they are over burdened with administrative tasks. So glad to see AI Grand Rounds giving a realistic picture of what is happening by in the field and not just hype. If we want real victories, we need to tackle at multiple levels, AI is absolutely a yes these days, but organizations should adapt and want to make provider lives better. AI Grand Rounds Dallas AI #RuralHealth #healthequity

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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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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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A brief thread on how MLR is often a stat that is juked (h/t to The Wire) in the “value-based” care world. The medical loss ratio (MLR) is a financial metric used in health insurance and managed health care to measure how much of a premium dollar an insurer uses to pay medical claims and quality improvement activities. The MLR is also known as the medical care ratio, medical cost ratio, or medical benefit ratio (cite: Healthcare.Gov). Many so-called value-based care models cite their impact in the form of medical loss ratio improvement. Most innocently assume that such improvement is generated by better medical management (I did when I first started working in the field). While this may be the case in some models—it is importantly to note that another way to improve a medical loss ratio is be increasing revenue capture in the form of coding. Said another way, to improve MLR, one can reduce the numerator or increase the denominator. Therefore, when someone cites a major medical loss ratio improvement—the key question to ask is: did the MLR improve because of true medical utilization reduction or because of better revenue capture? Most will glibly (and sometimes dishonestly) say “both.” At which point it’s important to ask, what fraction of Medical Loss Ratio improvement arose from better medical management and what fraction from better revenue capture. Usually, what we will find is that most dramatic improvements in MLR are a function of improvements in revenue capture—and only marginal improvements in medical cost-management. In that way, the so-called “value” produced by many value-based care models isn’t true value. It’s better revenue capture. And many “value-based” care models have been granted undue recognition for medical cost management—citing filthy MLR improvements—that are associated with minimal true improvement in medical expense. This kind of short-cut taking sets back the whole value-based care movement which (while appropriate revenue capture is necessary) should be about overall better cost management and reducing total cost of care—not better revenue capture alone.

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The Illusion of Efficiency in Healthcare: A Deep Dive into ACA's Impact Remember the argument on the quality and efficiency of healthcare during the ACA debate? This argument led to policy changes in the ACA that facilitated hospitals buying up physician practices and insurance companies owning pharmacies and benefits managers—both industries becoming big in the process. The notion was that by becoming big, both industries could bring in efficiencies by eliminating wasteful expenditures. But what happened? Both industries consolidated their market share and raised prices for the consumer. Hang on, one might argue that while we could not reduce the cost, we have improved the quality, and quality comes with a price. Fair argument, right? Has the quality of care improved? Well, this paper answers that question with a resounding NO. At least in this study, the quality of healthcare—as measured by in-hospital mortality, 30-day mortality, and 30-day readmission rates among a select patient population of a large independent cardiology practice before and after their integration with a large academic health system—did not improve. Another argument used in the ACA debate was that vertical and horizontal integration would reduce the utilization of services such as labs and scans because they would be more easily accessible through electronic health records. Has this argument survived research scrutiny? Again, the answer is NO. This study found no difference in the utilization of services when comparing before and after integration. Funny enough, I asked Google AI, “Does integration of outpatient practices with hospitals improve quality?” The Google AI overview gave me this answer: “Yes, integrating outpatient practices with hospitals generally leads to improved quality of care by facilitating better coordination of patient care, streamlined communication between providers, and access to more comprehensive services across different healthcare settings, ultimately enhancing patient outcomes,” and provided a list of references. All of them were review articles by influencers saying how “it feels good.” None of them referenced how “it felt good.” I hope the L!nk€d!n algo will pass this post in its quality check. What are your thoughts? #Healthcare

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One of the more well written pieces on ACOs, MSSPs, APMs, and primary care payment reform. ACOs make sense in theory and may be the most viable version of VBC. The article nicely outlines current challenges and potential solutions. Still, it seems like were not quite there yet. ACOs and newer models CMS (like TEAM and Making Care Primary) seem to incentivize PCPs to take more ownership of specialty care -- reducing referrals, coordinating more post-acute care, and steerage to "in network" specialists. It's a hub and spoke model where the PCP hub is large and the spokes lead to (ideally) small specialist satellites. This seems a little backwards to me. Sure, the goal should be to avoid low value specialty care. But the goal should also be to ensure patients get high value, appropriate treatment -- not unnecessary delays spurred by capitation worries. Every link in the chain should be incentivized and rewarded to do what they do best, not pitted against each other in a tug of war for bonus payments or shared savings. Do we want PCPS bogged down trying to deliver and coordinate specialty and post procedural care or do we want to free them to focus more on preventive care, patient education, and chronic care management? BPCI and CJR taught us that getting specialists to think more holistically about patient health can be effective. Patient optimization and stewardship of postacute resources in these programs is critical to success -- clinically and financially. In other words, primary care was migrated more into specialty care (instead of the opposite). Figuring out care coordination, who owns what part of the care journey, proper incentives, etc. is complicated and challenging when trying to tether primary and specialty care. Maybe the answer is to separate the two. Condition specific, population level ACOs tied to a diagnosis for specialists and proper reward for prevention, education, and chronic care management for PCPs. Or maybe I had too much coffee this morning. #medicine #healthcare #health #healthcarepolicy #vbc #valuebasedcare

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In 2026, 🇨🇦 NPs, pharmacists & midwives can bill the government for medically necessary, primary care services. What are the ramifications? First the quick rundown: → Currently in 🇨🇦 mostly physicians can bill the government directly for their services. This means in a private practice, the cost of NPs must either be covered by (1) the physician’s billings or (2) for some clinics recently (especially the newer NP-led ones), direct charges to patients. → The federal government (and many stakeholders) were unhappy with patients being charged for medically necessary primary care service, so they “re-interpreted” the Canada Health Act in a way that avoids patients being charged for these services - while still allowing primary care to evolve beyond 1-on-1 physician care (which is still the case for most patients). → This is also meant to reflect the increasing scope of practice that pharmacists, midwives, etc. have had as well in primary care. For example, in Ontario since 2023, pharmacists have been able to assess and prescribe a range of minor acute ailments (e.g. uncomplicated UTIs) that previously could only be treated by physicians. → This change will take effect in 2026 to give provincial and territorial governments a year to prepare for these changes So… what are the likely ramifications of this change? What thoughts are running through my head? → Will NP-led brick and mortar clinics grow? I’m unsure… because it depends so much on how much they can bill. If many physicians are leaving private practice because it’s increasingly unsustainable… will the amount NPs bill be enough to make a clinic work? What if NPs actually make less than they do now charging privately? → NPs working at existing (often physician-run) clinics WILL grow - because NPs being able to bill directly will offset the salaries the clinic has to pay them. Physicians “should” love this because it should increase their clinic margins (and thus takehome pay). It should also allow NPs to potentially make more than in the NP-led clinics as they can share the overhead. → This in turn should make team-based primary care even more attractive for all parties involved. Essentially more money flowing in for team-based care. → Does this actually change anything for pharmacists? Retail pharmacies in provinces like Ontario already bill the government (e.g. minor ailments) - but none of that money goes to the pharmacists (it goes to the pharmacy). → Most doctors (by default) are going to dislike this because they worry this is continued “scope creep” into their “territory”. I expect the medical associations to come out with a strong stance against this. → Will NPs also have telemedicine billing codes, meaning NP virtual care will skyrocket? My HOPE is that this makes team-based primary care more attractive. BUT the more we just push more fee-for-service as the solution… the more we keep doubling-down on a payment model that we know isn't’ sustainable. What do you think?

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On October 8th, U.S. News & World Report released its annual rankings of Children's Hospitals, called "Best Children's Hospitals". It is a 174-page report describing the methodology and data tables which I scanned through. Appendix C-10 has the data on Pediatric Pulmonology which I took a deep dive into. In the attached carousel, I have recreated two datasets that matter. If I were to shop around for a hospital for my care, what really matters to me is the outcome data for a particular condition I am seeking care for and not the reputation score. However what separates the top-ranked "Best Children's Hospitals" is their reputation scores, not the outcome scores for selected conditions as in asthma here. It's a different matter whether the outcome scores used in the rankings are good measures. We will discuss them in another post. What are your thoughts? Feel free to like, share, and comment. #healthcare #hospitals #physician

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Asymmetry in the leverage between payers and those who deliver healthcare has a disproportionate impact on the patient. Labour costs are rising and revenue does not keep up with the pace of medical inflation net of labour cost. It does not take an advanced degree to realize that with this imbalance, the patient feels the squeeze in the form of reduced access to services and/or increased out-of-pocket spending in an already tight economy. The market is neither free, nor balanced. It has no hope of achieving balance without installation of reimagined checks and balances. Increasing the bureaucracy, though, is a costly solution. While all sides can and must improve their transparency, there is little financial incentive to do so. QuickHealth seeks to upend this information asymmetry with targeted technological solutions for patients and primary care providers. Using AI-assisted Consumer Medical Education resources, we are empowering patients to work collaboratively with their primary care provider to enhance the patient’s well being. Our cost neutral, net revenue positive solutions aim to improve patient outcomes. When patients feel empowered and educated, the entire healthcare system benefits. Healthcare does not have to be a battle. Ask how QuickHealth can help. #HealthcareReform #HealthcareEconomy #FreeMarkets #RegulationReform #HealthcareEquity

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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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Title: Bridging the Gap: Public and Private Healthcare Collaboration On June 11, we hosted a pivotal meeting with key voices from both private healthcare providers and public healthcare regulators and providers. The consensus was clear: collaboration between the public and private sectors is essential to create a robust and sustainable healthcare system. Here’s how we can achieve this: 1. Unified Vision:Establish common goals like improving patient outcomes and increasing accessibility. 2. Leverage Strengths:Public systems excel in broad coverage and preventive care, while private providers lead in innovation and efficiency. 3. Data Sharing:Integrate data to enhance diagnosis, treatment, and preventive measures. 4. Joint Investment:Collaborate on funding for advanced medical technologies and telemedicine. 5. Policy Harmonization:Align policies to reduce bureaucratic hurdles and foster innovation. 6. Public-Private Partnerships: Pool resources to tackle infrastructure and rural healthcare challenges. 7. Continuous Improvement: Regular feedback and communication to adapt to changing needs. Our meeting highlighted the potential of collaboration in transforming healthcare. By working together, we can build a more efficient, equitable, and responsive healthcare system. Let’s commit to this collaborative journey for a healthier future. #UHC #medicalai #health #PPP

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What would it take for CMS to actually have sufficient primary care by 2030. Spending in primary care would need to go up, not down as in 5.8% to 4.6% of total spending as indicated by the Milbank Scorecard 2010 to 2020 (purple squares at bottom). Flat lined 250 billion in primary care spending with cuts and new types of costs added can only decline capacity by about 20 - 30 billion or 10% of capacity year after year due to less workforce and other team members supported (green line). Worst case orange line reflects cuts, higher turnover costs, even worse retention, and higher costs of delivery. Primary care delivery capacity should have continued to increase slightly faster than population growth (purple line), ideally at 2% annual increase (turquoise) to cover population increases and increases in a number of complexities. Fewer and fewer primary care years per class year indicate declines, not advances. Primary care retention would need to increase. It continues to decline for all 5 sources decade after decade. CMS would have to prioritize delivery team member numbers and quality while decreasing metrics, micromanagement, and team member burdens. CMS would have to focus on volume increases rather than volume to value. In primary care, volume is what enhances access. In particular the cost cutting and overutilization focus must go away for 40% of the nation with half enough primary care and basics where underutilization and inappropriate utilization worsen by the financial design. The nation would have to address the fatal flaw of employer based health insurance - payments lower than cost of delivery where the weaker employers are concentrated. CMS would have to increase payments to 110% of the cost of delivery, up from 60 - 85% CMS would need to audit its plans and discipline them such that lower payments are not associated with lower levels of workforce - as in 15% lower office payments for primary care where it is half enough for 40% of the population in 2621 counties across vast regions. Primary care year production since the class of 2010 needed to exhibit regular annual increases in the numbers of primary care years from IM NP FM PA and PD (blue line) CMS would have to look back historically and see that the only major increase in primary care was 1965 to 1980 with the new billions from the original Medicare and Medicaid design (blue line left) CMS would need to understand that no training design, especially graduate medical education funding, can address deficits of primary care and basics where the public plans and worst private employer based plans are concentrated. CMS would need to see that its designs prevent improvements in PC delivery capacity including regulatory capture, RBRVS, budget neutrality, and better payments and more lines of revenue for those larger - especially when CMS votes its 1.4 trillion annual budget against basic health access.

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I get Dr. Yang's concern about large, wealthier health systems adopting AI sooner than smaller, poorer organizations, but this is actually a good thing...unless your time horizon is myopically short. Big organizations, with much larger budgets and sophisticated IT teams, can afford to take risks, make mistakes, and test out exciting (but still unproven) emerging tech while smaller organizations certainly can't (for the most part). So let the behemoths take all the risk, do the heavy lifting first, and then smaller organizations get to adopt truly proven solutions at lower risks/prices...once these have run the Kaiser, Mayo, Intermountain, etc., gauntlet. It's all part of the plan... #healthcare #startups #startup #ai #generativeai #digitalhealth #emergingtech Kaiser Permanente Cleveland Clinic Mayo Clinic Risant Health Intermountain Health https://lnkd.in/gckgQB_q

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Walmart joins so many others in quickly entering and leaving or scaling back in healthcare after ambitious plans to scale. This morning, Walmart said it will close all 51 of its health-care clinics, as well as shut down their telehealth virtual care services. This is right after an announcement in March that they wanted to double the size of their clinical operations by opening up over 20 more locations this year and more next year. The reasons they cited? “Like others, the challenging reimbursement environment and escalating operating costs create a lack of profitability that make the care business unsustainable for us at this time.” As a physician, it’s been fascinating to watch over the past few years as so many non-medical companies try to get their bite of the huge percentage of the GDP that is healthcare. They pour money into trying to deliver healthcare at scale, ignoring the many concerns that hospital systems and physician private practices have been citing for years: declining reimbursements, shortages of clinicians, and expensive labor costs. Healthcare is broken, and those that are in it understand why. Patients need - and deserve - quality health care. This requires safe staffing practices, skilled clinicians who can feel good about what they do, and insurance companies that pay their bills. We can’t have a system where insurance companies can get away with record profits while finding more and more reasons not to pay for care and eroding away at the heart of healthcare. You cannot scale your way out of America’s healthcare problem. You actually need to fix the incentives, regulate insurance companies, pay clinicians appropriately, prioritize clinician well being and retention, and focus on the patient. The days of paying lip service to physicians leaving medicine and physician burnout are numbered. Supply and demand forces will necessitate real solutions that move the needle. Companies will come and go in the healthcare space when they realize how hard it is on the ground in healthcare these days. The question for patients and legislators is, who will be left to pick up the pieces if there’s no support for physicians, other healthcare workers, and hospital systems?  The percentage of clinicians leaving healthcare annually because they no longer recognize the heart of why they joined the profession is astounding, with over 1/4 of clinicians looking to leave within the next few years. Relying on the altruism of clinicians and the erosion of quality healthcare to support profits for corporations is just not a sustainable business model in healthcare - not to mention terrifying for public health. #HealthcareOnLinkedIn #PhysicianBurnout #PhysicianShortage #Walmart

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