Robert Bauer, Jr., LFACHE

Full Medicaid expansion needed to retain Georgia’s physicians Georgia was ranked 5th worst place to practice in a recent Medscape article (“Best and Worst Places to Practice 2024”), using five criteria: physician compensation, cost of living, malpractice premiums, the health of the state’s residents, and physician burnout levels. As current and future physicians and health advocates, this column will add context by detailing our experiences practicing in Georgia. It is no surprise that three of the five worst-ranked states for practicing are among those that have not expanded Medicaid. In Georgia, refusal to expand Medicaid means that nearly 12 percent of residents (well over a million people) are uninsured, significantly limiting their access to healthcare. Only in Texas is coverage worse. Due solely to political concerns, Georgia chose to submit a Medicaid waiver and develop its own Medicaid expansion program, Pathways to Coverage. The governor’s office projected that the program would cover an additional 100,000 Georgians in its first year. But it has been an utter failure, with fewer than 3,500 covered at a cost to taxpayers of $26 million. Full Medicaid expansion would have added over 350,000 Georgians while cutting state spending by $710 million. These three states that refused to expand Medicaid are not surprisingly red. It is also unsurprising that the states with the greatest percentage of unhealthy residents are red. Hopefully, Georgia who thought they had a better way of expanding access to care with their own plan that squandered $26 million to cover 3,500 residents will realize that retaining physicians requires a more sensible approach to expanding access to care. #expandinghealthacess, #accesstocare, #limitingcoveragetoresidents https://lnkd.in/eefqH-9Y

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I hole heartedly agree Benjamin Schwartz, MD, MBA. Anywhere else in an economic system, innovators who can deliver a better product at lower costs are almost always rewarded with greater market share, and frequently set the direction for the future of a product or industry. Not so in healthcare. I think that Terry Adirim, MD, MPH, MBA (below) hit the nail on the head when she references for-profit health insurers in the mix. Although policies have been enacted with the idea of providing better healthcare at lower costs, they have always given the job of administering those policies to a middleman (insurance companies) whose motives are at odds with the objective they claim to be administering. Profit! Innovation is not in the best interest of the payer. They profit through the inefficiency of the system. Until this lack of alignment between quality patient care at low costs and for-profit health care plans is addressed, process innovation and improvement will only be able to nibble at the edges.

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🚨 Update on Baptist Health and Florida Blue Negotiations 🚨 Negotiations between Baptist Health and Florida Blue are ongoing and remain tense as the September 30 contract deadline approaches. Discussions have been underway since February 2024, but no agreement has been reached. The core issue is payment rates: Baptist Health seeks increases to cover rising costs, arguing that current rates are below market, while Florida Blue contends that these demands are excessive and significantly above inflation. With the potential for Baptist Health services to become out-of-network for Florida Blue members on October 1, many patients in Northeast Florida are left uncertain about their healthcare options. Both sides are committed to finding a resolution, but time is running out. 🔗 Sources: Action News Jax, Baptist Health, Health News Florida

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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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Exciting times at 4C Digital Health! Wilmington, Delaware - 4C Digital Health (4C), the preeminent organization delivering independent financial oversight and control solutions for self-funded employee health plans, recently announced the strategic expansion of its services into the Commonwealth of Kentucky. In late 2023, 4C successfully competed for an initial award issued by Kentucky’s Department of Employee Insurance, and Kentucky has since extended the initial contract to allow 4C to continue its important work on behalf of the Commonwealth, its employees, and its taxpayers. The Kentucky Employee Health Plan (KEHP) serves more than 288,000 members, which amounts to 1 in 16 Kentuckians. In addition, KEHP spends over $1.8 billion dollars in total healthcare benefits on behalf of its members per year and covers over 8.2 million claims per year. KEHP objectives include “improving employee health and well-being” and “providing state-of-the-art benefits while maintaining reasonable premiums.” Recognizing its important fiduciary responsibilities to its employees and its state health plan, the Commonwealth of Kentucky enacted Senate Bill 42 (2023) introduced by Senator Stephen Meredith for the purpose of ensuring that critical health plan dollars are being spent properly on behalf of state employees. The legislation requires that 4C analyze 100% of medical claims submitted for payment to KEHP; identify erroneous overpayments; and identify inappropriate or erroneous fees imposed by KEHP’s third-party administrator. Ron Templeton CEO of 4C Digital Health stated: “4C Digital Health is grateful to the Commonwealth of Kentucky for recognizing the fiduciary responsibility that state and local governments have to their employee health plans and for the opportunity to provide our services in support of this mission. We appreciate Kentucky’s goal of using 4C’s expertise and innovative solutions to improve healthcare outcomes and reduce healthcare costs for the Commonwealth, its employees, and its taxpayers.” About 4C Digital Health: 4C Digital Health (https://lnkd.in/eB-fJg4X) is a healthcare data analytics company that was founded for the purpose of developing a disruptive technology targeted at bringing transparency and honesty to the healthcare marketplace.

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🚨 #Nurses & #NurseLeaders: The Tennessee Falsified Records Case Should Wake You Up 🚨 By now, you’ve likely heard about the Tennessee #nurses accused of #falsifyingmedicalrecords, leading to the alleged deaths of patients in a #long-term care facility. Sixteen were released, but two remain in custody—banned from working by a CRIMINAL judge’s stipulations. This means the Board of Nursing (BON) will get involved, and their licenses are more likely than not suspended and on the way to being revoked. As a prior investigator this was a task that I would have to do. Here’s the harsh reality: ✅ Falsifying records isn’t just a long-term care issue—it’s a risk in every setting. ESPECIALLY #hospitals ✅ Staffing issues aren’t a defense in court or with the BON. No one can say it was related to staffing, then hire, get agency or transfer them it’s required. ✅ This condcut impacts EVERYONE: CNA,LPNs, RNs, DONs, even CNOs. 💡 What you need to know: BONs (under HHS or state health departments) hold individuals accountable at every level. #nursingLeadership and #staffnurses can face charges for actions within their scope—or failure to oversee others criminally, civilly and most certainly administratively. This is only the beginning unfortunately for these #nurses. These charges will follow them for life. With increased oversight and decrease in funds these cases will happen more often. I keep running the 🚨 alarms #nurses and #nurseleaders, If you think this couldn’t be you, think again. I’ve seen nurses and leaders lose their licenses for similar issues. Protect yourself, your team, and your career. 📢 Don’t wait until it’s too late and it affects your life and livlihood! If you have questions book time with me to stay ahead of criminal, Civil and BON investigations. Rebecca Love RN, MSN, FIEL Angie Gray Kasey Pacheco Celia McIntosh Ana A Julie Siemers, DNP, MSN, RN Francine Bono-Neri, PhD, RN, APRN, PNP, FAAN Kaye Mendoza Claire Hast Michelle Koehn Alicia Jenkins Kathleen Bartholomew Kristi Campoe, PhD, RN, CMSRN, CPHQ, sMBA Sara Fung, MN, BSN, RN Melissa Mills, RN, BSN, MHA Rosa Hart Dr. Lendra James DNP, MS, RN, NE-BC Demetrius Kirk, DNPc, MBA,MSN, RN, LNHA, LSSGB, PAC-NE, QCP Amy O'Shea, RN, BSN, OCN

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Want to know exactly what Medicare will pay your hospital for a specific admission and the impact a CDI query will have on the case? Google your hospital's "CMS provider number" -Systems may use the same number for multiple hospitals so you might need to dig a little Go to this website: CMS.webpricer.gov and click on "Inpatient PPS" Enter the following: Your hospital's provider number that you Googled Admit & discharge date: make them up to a recent time period Total charges: put 10K if unsure, it won't matter except for outlier cases Covered days: put enough days that cover the length-of-stay DRG: Google "MS-DRG Relative Weight table 5" to get a list of all DRGs Click "Estimate" and you'll see your hospital's payment on the right. You can also scroll down and see your hospital's "cost-to-charge ratio", which is a factor in outlier payments. You can click "Edit Claim" and enter higher charges if you want to see when outlier payments start to kick in or try different DRGs If you want to see the impact of a query that takes a case from a "W/O CC/MCC" (without complication/comorbidity, major complication/comorbidity) to an "MCC" (major complication/comorbidity), enter the MS-DRGs that go with each of those, so DRG 379 for w/o cc/mcc and DRG 377 w/MCC in the GI bleed examples in the slides. The attached slides show a snippet of the CMS relative weight table with GI bleed highlighted to show you the different relative weights of the three severity levels for that DRG. Other DRGs may have just one or two severity levels Next slide is a snapshot of the CMS CC/MCC list with "viral pneumonia" highlighted as a major complication/comorbidity (MCC) Last two slides show you how the payment is calculated for a hospital (UCLA in this case) for the GI Bleed MS-DRG and the impact of a query for "viral pneumonia" that increased the severity from a "WO CC/MCC" to "W MCC" This isn't just for adult patients. There are 12 states that pay Medicaid by MS-DRG and plenty of commercial payers in every state that pay by MS-DRG. Contact Pediatric Resource Group (PRG) to help you develop or optimize CDI for your pediatric/neonatal patients. Don't have peds? We have an adult consulting division as well called Physician Resource Group (PRG) #CDI #revenuecycle #hospitalfinance #MSDRG #CFO #clinicaldocumentation

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CarePoint Health System's most recent bankruptcy reflects years of financial struggles, legal disputes, and attempts to salvage its healthcare operations. Ironically, it was formed in 2013 when three hospitals—Bayonne Medical Center (BMC), Hoboken University Medical Center (HUMC), and Christ Hospital— were purchased out of bankruptcy. Financial strain and management controversies plagued the network, particularly after reports surfaced in 2019 that former CEO Vivek Garipalli and other leaders funneled millions through shell companies, casting a shadow over CarePoint’s financial integrity. In recent years, CarePoint’s financial troubles deepened, with operating losses reaching 14% and significant debt accumulation, prompting the state to appoint a fiscal monitor. CarePoint repeatedly requested state subsidies to maintain operations, cut employee hours, and faced over $11 million in lawsuits from unpaid vendors. An intense rivalry with Secaucus-based Hudson Regional Hospital and its owner, Yan Moshe further complicated CarePoint’s stability. Moshe acquired the land beneath BMC in 2019, spurring legal battles over property control. Bayonne’s city council attempted to safeguard BMC’s future as a hospital through zoning protections, leading to a prolonged court dispute that recently concluded with a ruling in favor of preserving the hospital's function. Despite their adversarial history, CarePoint and HRH recently forged a tentative partnership to create a unified healthcare network, a deal brokered by Jersey City Mayor Steven Fulop. However, just weeks after this announcement, newly appointed CarePoint CEO Dr. Jawad Shah abruptly resigned, leaving CarePoint without a clear leader and triggering renewed uncertainty. Following Shah’s departure, HRH promptly offered $25 million in interim funding to help CarePoint avoid liquidation. HRH proposed to integrate HUMC, Christ Hospital, and BMC into its network, which includes its existing facility in Secaucus, with hopes of forming a stable, regional healthcare system. The Hudson County community and union representatives have since called for a state investigation into CarePoint’s financial management. To keep this story very "New Jersey" its also worth noting that HRH’s recent public image suffered a blow due to the arrest of its marketing director, Reuven Alonalayoff, who was found with an arsenal of weapons and ammunition in an unlocked hospital office. This prolonged crisis raises a pressing question for New Jersey’s state leadership: why wasn’t more done to prevent this unfolding catastrophe? For years, warning signs were not only apparent—they were glaring. Mismanagement, spiraling debt, and questionable practices were well-documented. As a critical safety-net system, CarePoint’s facilities serve some of the most vulnerable populations in Hudson County. When we have a crisis in leadership, patients and communities suffer. Full stop. Kevin Lyonsjeff lestonJohn TozziAnna Mathews

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Proof of Purpose; PDPs kept afloat Good for Manufacturers, too? The intricacies of IRA Part D benefit redesign dramatically reshape the OOP for millions of beneficiaries, reducing financial toxicity and raising utilization (I will post to past non adherence figures in comments) Unlike MA PDPs, freestanding PDPs can’t shuttle money over from the medical benefit to moderate premium increases, so some speculated that PDPs would fail. I commented several times that given this administrations view of the private market exemplified by MA that was highly unlikely. And after all PDPs are holding up half the benefit. CMS moves forward. “CMS is also announcing a voluntary demonstration program for standalone prescription drug plans (PDPs). The Part D Premium Stabilization Demonstration is designed to test whether additional policy changes stabilize year-over-year changes in premiums for participating standalone PDPs, leading to more predictable options for beneficiaries during the initial implementation of the IRA’s) benefit improvements, creating more gradual enrollment changes… Under the voluntary demonstration, there will be a reduction in the base beneficiary premium of $15 for all participating PDPs, combined with a year-over-year plan premium increase limit of $35 and narrowed risk corridors..” Thanks Tom Thoughts on implications, such as spillover from reducing headwinds, moderating adoption of narrower formularies and networks? If so possible plus for Phrma —not to mention if it slows down MA train with attendant Part B drug prior auths. #PartD #PDPs

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Managed Care Negotiation Best Practices - 2025, Class 2. Negotiating Targets and Rebalancing •Know the facts, not the nonsense the insurance cartels and the academics/think tanks report. According to Millman, national commercial reimbursement rates for states range from 136% of Medicare to 266%. You are being underpaid if your rates are below the national average and/or below the average for your state. https://lnkd.in/gJn8xF6y •The average commercial inpatient reimbursement for each state ranges from 152% of Medicare to 261%, with a national average of 202% •The average commercial outpatient reimbursement for each state ranges from 137% of Medicare to 357%, with a national average of 252%. Note: these rates apply to ASCs as well •The average commercial professional reimbursement for each state ranges from 115% of Medicare to 252%, with a national average of 147% - Health systems need to do a better job negotiating professional rates for their affiliated physicians. •Again, the rates you NEED are based on your mix, i.e., Medicare, Medicaid, Commercial, and Self Pay, and the management effectiveness and efficiency of your organization – it is a straightforward calculation •Like hospitals, the insurance cartels must publish their rates. However, they have made it very difficult to analyze their files. If you want assistance with a local rate comparison, contact John and Pete at After Transparency https://lnkd.in/gHDVBEtS •You can’t fight gravity; GI, Orthopedics, Imaging, and several other procedure-based specialties are (and should be) moving to the outpatient setting. Counting on HOPD rates for these outpatient services is a fool’s errand. •Rebalance the commercial fee schedule so that service revenues migrating to the freestanding outpatient setting are priced below traditional HOPD rates but significantly higher than the commoditized rates being offered by the insurance cartels (i.e., At a minimum, target rates of at least 200% of the outpatient Medicare fee schedule) •The revenue reductions in the outpatient rates should be rebalanced to hospital-centric services such as neurosurgery, ED, and NICU. Ultimately, your organization must base its commercial pricing on:  Revenues-Expenses= Survival So it goes n8 Stay tuned for Class 3 - Preparing for the Unwillingness of the Insurance Cartels to Pay Physicians and Hospitals Fairly #hospitals #healthsystems #healthinsurance #healthinsurance

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The conversation around the recent proposed 2.8% cut to Medicare physician payments for 2025 is intensifying. This marks the fifth consecutive year of cuts, following a 1.69% reduction in 2024 and a 2% drop in 2023. Check out the trend analysis from Hospital to Physician from the #AMA. It's mind numbing👇 https://lnkd.in/gtVN5wNa. The reality is that some physicians may be forced to leave private practice and become employed physicians due to these financial pressures. Unlike private equity-backed groups, some private practices often lack the financial support to absorb these cuts. If you're facing this dilemma, as some of my clients are, my advice is to tread carefully and do thorough research. Analyze your reports and evaluate whether your practice can survive despite these reductions. I've also noticed that many practices still face unnecessary denials from non-Medicare payers, which, if addressed, could help offset these payment cuts. Additionally, there are often inefficiencies within staff roles where technology could boost productivity. Before making the leap to becoming employed, consider all the implications. And if you must make that transition, ensure you secure a solid contract. Make sure the CFO understands your needs and rights, and that they have a capable billing and coding team that will accurately capture the RVU value you're entitled to. I'm always here to advocate for physicians. 💪 #HealthcareAdvocate #MedicareCuts #PrivatePractice #PhysicianSupport

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Wondering why the American Hospital Association is slamming the FTC's final rule on non-competes? Read on.... Excerpt from FTC Commission Non-Compete Clause Final Rule: "...the Commission disagrees with commenters’ contention that all hospitals and healthcare entities claiming tax-exempt status as nonprofits necessarily fall outside the Commission’s jurisdiction and, thus, the final rule’s purview. As explained in Part II.E.2, a corporation’s 'tax-exempt status is certainly one factor to be considered,” but that status is not coterminous with the FTC’s jurisdiction and therefore “does not obviate the relevance of further inquiry into a [corporation’s] operations and goals.' "Similarly, whether the final rule would apply to quasi-public entities or certain private entities that partner with States or localities, such as hospitals affiliated with or run in collaboration with States or localities, depends on whether the particular entity or action is an act of the State itself under the State action doctrine, which is a well-established, fact-specific inquiry. "Thus, some portion of the 58% of hospitals that claim tax-exempt status as nonprofits and the 19% of hospitals that are identified as State or local government hospitals in the data cited by AHA likely fall under the Commission’s jurisdiction and the final rule’s purview..."

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CVS Health's recent decision to buy Hella+Health Hella Health, a Medicare Advantage (MA) broker that also deals with competitors' plans. While leadership at Hella+Health indicated in a LinkedIn post today that adding their capabilities will further expand CVS's technological and brokerage capabilities and give seniors a better member experience, I'm a bit skeptical on timing. The acquisition comes at a time when CVS is experiencing considerable financial strain in its Medicare business. The company recently announced a significant reduction in its earnings forecast for 2024 after encountering unexpectedly high medical costs from MA seniors. This scenario raises questions about the timing, financial wisdom, and ultimately the motives of expanding into MA brokerage during a period of volatility and tightened margins. Owning an MA brokerage, which offers plans from a variety of insurers - all of which are CVS competitiors, introduces significant conflicts of interest. What sort of influence will CVS be able to wield over which plans are highlighted or prioritized to consumers? Will competitors get a fair shake? What sort of compensation structures will be in play that might benefit one vendor to the detriment of the others? Competitor as gatekeeper is never really a great idea.

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Suggestions on Choosing the Right Healthcare Proxy Choosing the right healthcare proxy is one of the most critical decisions you can make for your health and well-being. A healthcare proxy is someone who will make medical decisions on your behalf if you are unable to do so yourself. At Patient Advocates of Southwest FL, we understand the importance of this role. Based on first-hand and the experiences of more than a few clients, I’m here to share some key advice to help you make the best choice: 1.      Trust is Paramount: Select someone who understands your healthcare preferences and whom you trust implicitly to make decisions that reflect your wishes, not their own. 2.     Availability Matters: Your proxy should be generally available and can be present when needed, especially in urgent situations. Confirm they are willing and able to commit to this responsibility. 3.     Knowledge of Medical Matters: While they don't need to be a medical expert, choosing someone with a basic understanding of healthcare or who is willing to learn about your specific health conditions can be immensely helpful. 4.     Communication Skills: Your healthcare proxy should be a strong communicator. They will need to discuss your care with medical professionals and potentially other family members, advocating effectively on your behalf. 5.     Legally Prepared: Ensure that your healthcare proxy is legally documented. It’s always wise to consult with a legal professional to verify all paperwork accurately reflects your choices and is binding. Choosing the right healthcare proxy is about more than just fulfilling a role; it’s about ensuring that your healthcare decisions are in trusted hands. Your health deserves the utmost care and preparation. #HealthcareProxy #PatientAdvocacy #MedicalDecisions #HealthcarePlanning"

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What is it that most keeps hospital execs up at night? This MedCity News piece suggests it's the inability to coordinate care effectively and at scale. That's obviously a problem that can have a significant impact on the #PX. What are you doing about it? #HealthcareLeadership #PatientExperience #CareCoordination https://bit.ly/3UqqX1Z

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Not fair and balanced Advertorial for Private Equity A total conflict of interest Immoral to destroy healthcare for opportunity to work for companies that profit on ultimately destroying USA 🇺🇸 healthcare as we knew it. People that worked for CMS should be banned from working in industries that profited from the decisions and have connections for future decisions to destroy the healthcare fabric No discussion of the negatives only the positives Consolidation leads to fewer choices for patients The cons for patients outweigh the pros for the investors. Profits over care ultimately leads to rationing of the care that is not profitable Management of PE selects doctors to interface that benefit from a hard line approach over providers that see quality issues and patient safety as important Cheerleaders 📣 for the profiteers

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NAIC is pushing #CMS to allow members to leave their #MA plan if their provider terminates their MA plan contract. If this is successful, what would you do? ⏩ Would you rethink Provider contracts, payments, engagement or incentives? ⏩ Would it change your UM/MM, denials or #PriorAuthorization strategy? ⏩ If member retention was suddenly on the line, would you change your approach to provider contracting vis-à-vis #CAHPS and #memberexperience to protect #StarRatings? As more providers leave #MedicareAdvantage and the industry outcry grows, this is a great time for reflection: Could your plan adapt fast enough to not only survive, but thrive, if NAIC is successful? The future of member trust, satisfaction, and retention could depend on it. H/T to Amy Lotven for this great find! #ItTakesAVillage to keep up with all of the moving pieces now that 50% of seniors are in MA!

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Bravo to Florida for fostering healthcare transparency! It's empowering from a patient perspective to drill into health procedure pricing by provider and county. Being able to shop for the most effective and lowest cost care drives market efficiences and pushes providers to focus on outcomes and patient experience. Here are 3 key sites to leverage to find transparent and cost effective care: 1) Florida Health Finder (https://lnkd.in/eebA2JgM) Easy access to health care quality data and facility location information 2) Prescription Pricing via MyFloridaRx (https://lnkd.in/e5APKyjj): Prescription pricing information 3) Procedure Pricing (https://lnkd.in/eg-zkFPu!): Procedure "care bundle" pricing

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