R. Wayne Blackburn, Pharm.D.

New CMS report: The Medicare Shared Savings Program (MSSP) continues to demonstrate its effectiveness in delivering high-quality care while generating significant cost savings. Key highlights from the report: - MSSP generated $1.8B in savings for Medicare in 2022 - 483 ACOs participated, serving 11 million Medicare beneficiaries - 99% of ACOs successfully reported quality measures - 54% of ACOs earned shared savings payments These outcomes reinforce that VBC can drive care quality while improving financial outcomes for the ACOs who participate. Check it out here: https://lnkd.in/dJDNU6-c #Valuebasedcare #healthcareinnovation #ACOs #Medicare

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In a move to streamline care, LA Care Health Plan which managed Medi-Cal and several other plans for low-income Californians is cutting back 24% of its prior authorization requirements. "This change aims to reduce administrative burdens and speed up patient access to necessary treatments," the article explains. This is good to see. Could significantly benefit patient care by removing unnecessary delays in treatment approvals. Devil is in the details but still good progress, particularly for the most vulnerable. Check out the article by Nona Tepper in Modern Healthcare at https://lnkd.in/evVP3eqP

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Learn how data management can elevate value-based care. Discover how to overcome data management challenges and drive better patient outcomes. Learn about the latest VBC trends, including CMS's goal for 100% Medicare beneficiary coverage by 2030 and the projected $1 trillion market value. Don't miss out on key strategies to enhance interoperability, enable real-time data access, and integrate external data sources for comprehensive patient care. Read our latest blog post to transform your healthcare organization's approach to value-based care: https://buff.ly/3xIRbo4 #ValueBasedCare #HDMP #HealthDataManagement"

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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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Health insurance Prior authorization rationing of physician recommended preventive, medical, surgical and palliative care occurs over 1 million times a day in America. Medicare Advantage insurance plans ration care causing delays, changes and abandonment of physicians recommended care 100’s of thousands of times a day devastating patient health and physician workflow. #quadrupleaim #vbc #valuebasedcare

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📈 #HealthcareAlert: Hospital & Prescription Drug Spend Projected to Surge by ~6% Annually Through 2032, with Medicare at the Forefront Recent projections from the CMS Office of the Actuary, National Health Statistics Group indicate a significant surge in hospital and prescription drug spend, with Medicare driving the most growth. 🤝 Reach out to learn more about how MDI Health is helping payers and risk-bearing providers reduce Rx and medical spend by $2,000 per high-risk member. #Medicare #PayerSolutions #UtilizationSpend #RxSpend #MedicalCosts 

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Confirm patient eligibility for Medicare Advantage, supplemental coverage, qualified Medicare beneficiaries, and more – all in one view. The industry’s most comprehensive Medicare eligibility solution delivers enhanced visibility to historical and future benefits, with a 4-year lookback to historical coverage and 4-month future coverage details. Plus, easily find patients’ Medicare Beneficiary Identifier (MBI) to streamline your front-end workflows and optimize reimbursement. Learn more about Medicare Eligibility Verification Software: https://ow.ly/YIZb50Riqx4 #MedicareEligibility

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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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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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Read LogixHealth's comprehensive review of the final rule in the 2025 Medicare Physician Final Rule Summary: https://conta.cc/4gJNShX The final rule governs payment rates and other critical reimbursement issues for dates of service starting on January 1, 2025.

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The growth of the health insurance marketplace is picking up steam, fuelled by Medicaid disenrollment. https://ow.ly/N1vW50Tafsq MMIT’s Erin Trompeter explains what these large-scale changes mean for providers, manufacturers, payers and health IT vendors. Get the insights by clicking the link in this post. #HealthInsuranceMarketplace #HealthInsurance #Medicaid

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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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A Don’t Miss Reveleer Webinar: Patient-centered Prospective Risk Adjustment Join CareOne Consulting's Donna Page and Reveleer's Roxanna Cross & Anthony Polizzi as they share their unique perspectives on the benefits – and challenges – of implementing a more holistic, patient-centric view to risk adjustment. Gain valuable insights into: • How a more holistic approach can improve care delivery and outcomes • Importance of clinical documentation • Value of securing data outside a patient's EMR • The role of HIEs • Challenges that will need to be overcome • Best practices to integrate holistic patient data into risk adjustment models When Date: August 21, 2024 Time: 10:30 a.m. PST / 1:30 p.m. EST Learn more and register here: https://bit.ly/3WQv5d4 #RiskManagement #QualityImprovement #ValueBasedCare #Integration #RISEwebinars #Reveleer

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📉 Elevance Health 3Q Earnings Recap: What Went Wrong? On October 17, Elevance Health reported its Q3 earnings, and the market reaction was swift—a 15% drop. The major culprit? A soaring Medical Loss Ratio (MLR) of 89.5%, up by 270 basis points from Q3 2023. The primary driver: Medicaid reimbursement misalignment, which has burdened payors across the board. The mismanagement of Medicaid redeterminations led to a per-member cost spike, which wasn’t matched by state reimbursement increases, pushing Wall Street into a broad sell-off of the “Big Six Payors.” 📉 Despite these challenges, Elevance’s revenue still grew by 5%, reaching $44.7B. Their membership remains steady at 45.8 million, with ACA and commercial gains offsetting Medicaid losses. Key Takeaways from the Earnings Call and 10-Q: • Medicare Advantage: Conservative bids for open enrollment amid CMS rate cuts. While Elevance improved Medicare Star ratings on 60% of measures, one of their 4-star plans narrowly missed CMS’s cut-off, costing them. • Medicaid: CFO Mark Kaye noted cost-per-member increases as high as 3-5x in some states, driven by a shift to sicker populations post-redeterminations. With half of the state rate adjustments set for January, there’s hope that reimbursement alignment will improve. • Carelon’s Growth: Low 20% growth anticipated as Carelon expands its specialty drug offerings, with recent acquisitions of BioPlus, Paragon, and Kroger Specialty. Their latest acquisition of Carebridge further solidifies Carelon’s role in Elevance’s growth strategy. The specialty drug assets will be driving new value for larger employers they seem to attract. • AI Investments: Elevance is pursuing AI to streamline internal operations and enhance member experiences. This investment is set to mature through 2025, aiming to improve productivity and personalization. While Wall Street’s reaction may seem like an overreaction, the strategic groundwork Elevance has laid—especially in Carelon and specialty pharmacy—positions them for a potential rebound. Expect Carelon to become a key revenue driver as Elevance navigates the current Medicaid headwinds. For a deeper dive into the Elevance Health earnings for Q3 feel free to read and subscribe to my substack! #Healthcare

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EARN 7 AAPC CEUs and/or 6 AAFP CMEs for $49!! Vast changes are coming to Medicare Risk Adjustment. Is your team ready? Workshop Agenda: ­Discuss the importance of managing HCCs year over year. What resources are available from CMS to help? When is the Advanced Notice published? What are the components of a risk score? How will CMS calculate risk scores for 2025? Review NEW and updated HCCs. What documentation is needed to validate payment? Sharpen your Auditing Skills – Group review of clinical documentation and coding for HCCs. Take a deep dive into the grey areas and red flags of HCC coding and clinical documentation. See what your team should and should not be coding. Dates and Registration Links: Friday June 28 - https://lnkd.in/eNW7jDgw Friday, July 26 - https://lnkd.in/emS6nP9x Visit https://lnkd.in/esDVsekk to view all upcoming events.

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New Research on Medicare Advantage: 💰 Costly for Taxpayers, 💡 Popular with Enrollees New research published today by University of Southern California researchers (link in comments) finds that Medicare Advantage (MA) – the private alternative to traditional Medicare – costs taxpayers 22% more per member, amounting to $83 billion extra every year. 😲 The researchers claim MA was meant to save money through competition, but loopholes in the payment system have caused overpayments to insurers. Here’s what’s happening: 📊 MA plans are paid more for patients who “seem” sicker, even if they aren’t. This “upcoding” makes plans look costlier than they are. 💰 For every $1 overpaid to insurers, only 50-60 cents goes back to enrollees through lower costs or extra benefits (like dental or vision). 📈 Meanwhile, MA enrollment is skyrocketing, now covering half of all Medicare beneficiaries. Many choose it for added benefits, but switching back to traditional Medicare can be tricky. What’s the fix? 🤔 Reforms like better payment audits, adjusting overestimated benchmarks, or accelerated the adoption of value-based care to ensure MA truly saves money. The goal: protect Medicare’s future while balancing benefits for enrollees. The bottom line: according to these researchers, Medicare Advantage has promise, but without reforms, taxpayers are overpaying. What do you think? 🩺🇺🇸 #MedicareAdvantage #HealthPolicy #HealthcareInnovation

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