Tom Peterson

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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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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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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If you’re a payer grappling with the best ways to manage care and costs as utilization rises and reimbursements slow, you will gain a lot of useful insights in a few short minutes with this video discussion I have with Mohamed Diab, MD, President of CVS Accountable Care. Dr. Diab brings unparalleled population health experience, supporting 70,000+ providers and 1 million attributed lives in Medicare risk-sharing models in rural, suburban and urban geographies across the United States. One key takeaway: It takes more and better data, especially social determinants, to build complete pictures of patients that are essential to delivering higher-quality care at lower costs. What’s more, it takes all of us, Dr. Diab says, to tackle this fundamental roadblock to transforming healthcare. “We definitely are not where we want to be as an industry when it comes to our healthcare data,” he told me. “It’s not easy but everyone needs to speak up about the need for better data.” Please tune into this new Abacus Insights Health Planning video Powering Accountable Care with Better Data and Analytics. It will be worth your while. 

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The Centers for Medicare & Medicaid Services recently announced the first states to participate in their new #PopulationHealth-focused payment model. The States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model is a voluntary, state total cost of care (TCOC) model designed to address population health in specific regions, reduce health disparities and lower #healthcare costs. States participating in this model will be responsible for the quality, coordination and cost of healthcare while receiving funding and additional tools to address current payment and equity challenges in their state. 💡 My thoughts: It's exciting to see how we continue evolving our thinking around value and innovation, looking across payers, states and state agencies to push some of these practices forward. Not only that, but the timeline of these models has also been extended from 3 years to 10 years – allowing us a longer period to gather more comprehensive learnings and understand if these interventions are having a true impact. Efforts like these help us more accurately assess if the current work we’re doing is making a difference. I look forward to following the development of this model and seeing how it plays out with the first cohort (Maryland and Vermont) in 2026! 

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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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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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This Thursday the Energy and Commerce Committee will hold a hearing on the Centers of Medicare and Medicaid Improvement (CMMI). Members of the Committee are expected to raise concerns and praise for the agencies' efforts to test and achieve savings in value-based payment models over the years. Since its inception in 2010, CMMI has tested many new payment models including bundled payments, multiple accountable care organization offerings, and the making care primary model. The agency continues to face challenges, such as finding ways to engage rural providers and solo or small physician specialty practices. Reps. Michelle Steel and Susie Lee and Sens. Markwayne Mullin, Kyrsten Sinema and Thom Tillis introduced the EASE Act (HR 7149 / S.4078) to encourage CMMI to create a new payment model for rural and underserved communities to reduce long wait times that many seniors and residents face in these communities when seeking care from a specialist. The bill was developed based on years of data collected and reviewed by OCHIN to help community health centers and rural hospitals improve care integration and create a new value-based payment model. While Congress looks for ways to improve outcomes and reduce costs; and medical schools continue to look for ways to grow the physician workforce, one pathway that would fill the needs of communities (especially rural areas) and prevent avoidable hospital admissions is the EASE Act which looks to utilize telehealth or e-consults to help our most vulnerable populations receive timely care

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🎙️ Exciting news! ClearPoint Health CEO, Jeb Dunkelberger recently joined the Healthcare Nation Podcast for an episode focusing on the policy and payer space. Dive into rising healthcare costs, challenges for SMBs, and innovative insurance models. Discover how ClearPoint Health is transforming the benefits space. Listen now! #HealthcareInnovation #AlternativeFundingSolutions #GetClearPoint #ClearPointHealth

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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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Discern Health is committed to transforming healthcare delivery through proactive, data-driven solutions. On Friday, our own Medical Terminologist Katherine Sutton presented at the 2024 LOINC Conference, showcasing how LOINC questionnaires can be better used at the point of care and in the building of predictive models to support proactive patient care. Read Katie’s blog summarizing her presentation, which includes how we’ve adapted LOINC questionnaires at Discern to inform care decisions, reduce risk, and ultimately improve patient outcomes, with the goal of ensuring quality care for an aging and complex population. https://lnkd.in/gnc3WhxQ We’d love for you to share your perspective in the comments! #HealthcareInnovation #LOINC #PredictiveAnalytics #PatientCare #DataDrivenHealth

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WEBINAR TOMORROW | This webinar will feature a panel discussion on key design choices for developing a primary care population-based payment model. Hear from the experiences of Medicaid agency staff in CO, CT, & MA. https://bit.ly/3Vgjwde

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As we settle into our regular fall routines, I’ve been thinking a lot about the state of healthcare so far this year and what I hope we can continue working towards as an industry in the final months of 2024. First, Surescripts latest data report backs-up the anecdotes we’ve all heard about how healthcare is hurting. But it also highlights how the industry can collaborate to eliminate barriers and enable meaningful health intelligence sharing between clinicians. The result? More accessible care for patients in communities across the country. Check out all of the insights we’ve gathered from our annual clinician survey and more trends in our full report -- link in the comments.   Next, healthcare technology innovation and interoperability: this is a big one. Last year, Surescripts supported 24 billion exchanges of patient clinical and benefit information, connected 2.14 million care providers and organizations that reached more than 99% of the U.S. population. This means clinicians spent less time searching for patient information – sending faxes or making phone calls to get what they need to make safe, quality and less costly care decisions with their patients. But we have so much more to do: pharmacists and other clinicians still say it is somewhat or very difficult to share patient information securely and confidently with other care providers (46% of pharmacists and 31% of other clinicians). And clinicians hope to see better access to clinical information: 85% of pharmacists and 57% of other clinicians said that they would place a high priority on connecting both pharmacists and prescribers with centralized information about their patients. We know that secure health intelligence sharing is essential for true care collaboration that improves patient care. We will be working alongside the The Sequoia Project's new Pharmacy Workgroup under the Interoperability Matters program. The goal is to advance interoperability and allow clinicians, including pharmacists, to have access to key clinical insights that help them provide care for their patients. Check it out at the link below. Lastly, I’m reassured and hopeful. Despite the differences in the services they provide, the clinicians, health plans and advocacy organizations who came together for the Evolving Care Team Summit in D.C. earlier this summer proved that, not only can we have meaningful conversations about ways to work better together, but we really do share the same goal of improving patient care. I hope this meeting will continue to inspire us to find ways to collaborate across the industry on issues like reimbursement and access to needed health intelligence for clinicians working as a team. It's this kind of collaboration that can help patients get the care they need and deserve and ultimately, it’s also how we can help healthcare heal itself.

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I had the pleasure of sharing insights in my latest article on CareSmartz360 where I share key strategies for home care agencies to navigate an ever-changing landscape. From leveraging tech like telehealth to enhancing staff training and focusing on client-centered care, the future of home care is all about adaptability. Read the article below. #HomeCare #TechInCare #Leadership

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Gain our free insights into how the recently released 2025 Medicare Inpatient Prospective Payment proposed rules will impact #GME funding here:

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News from First Report Managed Care Volume 21, Issue 2: The Centers for Medicare & Medicaid Services (CMS)'s AHEAD model aims to improve population health management by awarding funding to states and promoting primary care investment and enhanced equity measures, but implementation challenges and cultural shifts may hinder its success. “States have relationships with many of the stakeholders whose perspectives and support will be vital to the success of this model,” Maureen Hennessey, PhD, SVP, director of value transformation at Precision AQ, told First Report Managed Care. Access the full issue here: https://lnkd.in/eKAWrpWp #FirstReportManagedCare #FRMC #CMS #AHEADModel #PopulationHealth

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AAPC recently published an article by one of our partners, Alyssa Foster, highlighting a key Medicare inpatient payment policy change for FY 2025 that can result in improved hospital inpatient payment for patients with documented inadequate housing or housing instability. #HealthPolicy #SocialDeterminantsOfHealth #Medicare #HealthcareInnovation #Reimbursement

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Key Strategic Insights = A Successful OP CDI Program The challenge of value-based care starts with a collaborative approach, when launching an Outpatient Clinical Documentation Integrity (OP CDI) program. Here are some key strategic insights to success: 1. Engage with Population Health Understand Pain Points: Begin by understanding the specific challenges faced. This fosters collaboration. Tailored Questions: Use customized questions to facilitate productive discussions and ensure alignment with needs. 2. Effective Software Implementation Manage Patient (Pt.) Volumes: Implement software solutions to efficiently handle pt. volumes. OP CDI Calculator: Utilize a calculator to determine Full-Time Equivalent (FTE) needs. Data Analytics and Reporting: Emphasize the importance of continuous improvement via data analytics. 3. Workflow Creation Establish Robust Workflows: Create strong workflows before integrating reviewers. 4. Collaboration & Communication Promote Strong Collaboration: Encourage robust communication between key stakeholders. Leverage Software: Use technology to reduce physician burnout & streamline communication. 5. Patient-Centered Approach Address social determinants of health (SDOH) & ensure accurate documentation of conditions and care plans. Patient Outcomes: Keep patient care at the center of all doc. & workflow processes. 6. Regulatory Compliance Adhere to Guidelines: Follow regulatory requirements such as CMS guidelines on Hierarchical Condition Categories (HCC) coding to avoid penalties and enhance credibility. 7. Measurable Outcomes Set Clear Goals: Aim for measurable outcomes like improved HCC recapture rates, enhanced RAF scores, better HEDIS measures, and addressing SDOH needs. 8. Stakeholder Engagement Involve All Stakeholders: Ensure that executives, clinicians, and other relevant parties are involved in planning and implementation process. Success Stories Recently, I helped several CDI directors validate their cases for OP CDI programs within Accountable Care Organizations (ACOs). By engaging with population health leadership, we identified key issues such as RAF gaps and HEDIS measures, and tailored processes to address them. For instance, a CDI director I guided successfully identified HCC and HEDIS recapture as their biggest pain points. With strategic solutions in place, they are now ready to implement the project for the 2025 budget yr., aiming to improve their HCC recapture rate by 20%, leveraging data analytics for outcomes and improvement needs. Benefits of Implementing These Strategies Align Risk Stratification: Properly align risk stratification with chronic conditions and healthcare needs. Quality Measures: Improve quality measures and address SDOH. Collaborative Team: Ensure success with a collaborative team supported by technology. Overall, these strategic actions will enhance patient care and operational efficiency. #Healthcare #Leadership #CDI #PatientCare #ValueBasedCare #HealthcareInnovation

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