Zwelithini Tunyiswa

I have written before with conviction and faith about NADAC pricing for drugs reimbursed to pharmacies. Why retail and independent pharmacies cling to faulty PBM contracts with the usual suspect of reimbursement benchmark of AWP. AWP is archaic and it certainly does not favor a pharmacy. As a Founder & CEO of a Hospice PBM and my past business experience of owning a pharmacy for over 20 years - pharmacies especially the independents have a soft place in my heart. That is why I believe treating the independent pharmacy as your partner we can all share in the success of the paying client or the customer as a happy customer. Margins are tight and the squeeze is tightening further. CMS gave all hospice providers a 2.5% increase. In the hospice PBM world think of it this way the average national cost per patient per day is around $12.50. Now reflect on all other nursing costs, visit costs, caregiver costs, aids etc and then you realize AWP is hurting the paying client not helping. Cap Rx keep on, keeping on!

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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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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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With massive variation in star ratings, health plans often resort to unsavory, non-transparent tactics to bolster their ratings. Here are a few: Novation: plans will merge a low performing contract in one geography with a higher performing contract in another geography, blending the performance of a low-performing cohort of people with a higher performing cohort in another / overlapping geography. Star ratings may look higher to the public but there has been no fundamental improvement in performance. Contract area expansion: a health plan will take a high-performing plan in one geography and file an expansion into a new geography (including one in which they already have a lower rated plan). This also reflects no fundamental improvement in performance—and deceives the public into thinking that a plan is better than it is. These tactics are clever. And can lead to transient “improvements” in star ratings that are hard to maintain. But they also waste the taxpayer’s money because it is rewarding a plan for no *real* improvement in performance. *Shareholders and equity research analysts of these plans (and potential acquirers) should also catch on to the fact that these tactics—which drive transient earnings bumps—don’t really reflect fundamental improvements* *And brokers should be aware of these shenanigans when lower rates plans suddenly show up in a market with markedly higher star ratings than they earned in previous years* *Even most employees of these companies don’t understand these tactics and how they are used to “enhance” ratings* ******* Novation and overlapping area expansions are dirty secrets of how health plans (not named SCAN) manipulate Star ratings without any underlying improvement. Health plans that engage these loopholes don’t serve the public well and the Centers for Medicare & Medicaid Services guided by the Medicare Payment Advisory Commission should work to close them in the best interest of American seniors.

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📢 The 2025 final Medicare Physician Fee Schedule dropped yesterday and there are two really significant changes impacting health tech. (1) CMS finalized coverage for digital therapeutics for mental health. This is the first time there is codified coverage for software-only digital therapies (that have gone through a 510(K) or De Novo pathway). The CPT Editorial Panel also expanded the definition of RTM codes starting in 2025. Together, these changes open the door to coverage and payment for digital therapeutics (though uptake will still be an uphill battle without much stronger clinical evidence). (2) CMS finalized coverage of advanced primary care management codes. These codes can be used instead of CCM, TCM, PCM, eConsult and eVisit codes, and shifts focus for providers and tech-enabled services companies from tracking time to developing capabilities that underpin advanced primary care. Providers will be able to bill for these services once per Medicare beneficiary per month so long as the practice has in place the capabilities to provide advanced primary care. Also some good news related to some operational telehealth flexibilities but we still need congress to act before the end of the year to extend the most important flexibilities (originating site and geographic restrictions). Manatt Health will have a more full summary in the coming days.

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Dr. Jain...THANK YOU for this insight and support for the kind of work I do every day! Building complex geriatrics longitudinal care programs is where I cut my value based teeth! These programs - when structured with attention to detail - can create a profoundly positive impact. A fully integrated program that is carefully facilitated, orchestrated, and navigated WITH a patient quite literally changes lives. As a system we have to shift our thinking and embrace the FACT that cookie cutter medicine is NOT effective as well as the notion that precision medicine is not scalable, replicable or sustainable....because it CAN be. Been there, done that (and continue to do it) and have the results to prove it! At Synergy 3C, THESE are the models we build and have a track record of success! We would love to have a conversation with you about HOW these models can and do work! #complexpopulationhealth #complexgeriatrics #medicareadvantage

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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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Reason #3 why geographic restrictions are bad policy for #340B contract pharmacies. Increased Patient Costs – Many patients have chosen or are required to use a home delivery service provided by their insurance company. In many instances patients have access to lower copays through the pharmacy of their insurance company. Limiting the ability to contract with distant payor related pharmacies will prohibit covered entities from working to provide patient assistance programs with their patients’ chosen pharmacy and poses the risk of increasing the out-of-pocket costs of their patients for no good reason. Health Resources and Services Administration (HRSAgov), HHS Centers for Medicare & Medicaid Services National Association of Community Health Centers (NACHC) PhRMA #340B #CoveredEntities Advocates for Community Health

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I always learn from Alexander McKinney MD, CI-CIIP In AI, I initially thought we had a problem: How do we prove the outcomes associated with AI? How do we know that triaging a patient correctly, not missing a finding, or making an accurate measurement actually improves outcomes? Over time I learned that we are not alone! As Dr. McKinney brilliantly outlines, the issue is the same for radiologists and other diagnosticians. It's actually the problem of healthcare fragmentation and how to prove the downstream impact of better quality. When Cedars-Sinai and Yale New Haven Health came out with studies showing Length of Stay reduction for AI. These were really not studies about the impact of AI. Those are studies about the downstream effect of improving quality of care in their radiology departments. AI was merely the enabler. As a healthcare ecosystem, we need to evolve how we measure impact. Dr. McKinney taught me about relevance, impact, and outcomes. By focusing on these, we can understand the power of better quality and invest in what truly improves health.

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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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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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Hospitals, Medicare's 2030 goal is clear: 100% of payments in Value-Based Care (VBC). No one’s off the hook. CMS struggled to get specialists and hospitals into programs like Bundled Payments, so now participation is mandatory. Hospitals that resisted VBC have no choice. The Transforming Episode Accountability Model (TEAM) locks them into a system where every dollar is tied to patient outcomes. This isn’t a suggestion; it’s a mandate. Care coordination, cost control, and patient health are now non-negotiable. The era of fragmented care is ending. Hospitals must adapt or face the financial consequences. If you're navigating these changes and need a partner who understands the landscape, let’s connect. Medicare’s vision is clear, and the path to 2030 just got a lot more serious. https://lnkd.in/eT8GQqd4

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The 'payvider' becoming a healthcare delivery niche player. It appears all outpatient...infusion, pharma, home health, urgent care, etc. Seeing more signs of consumers being directed by payers. No real, big box hospital purchases. Are beds being isolated and commoditized? #hospitals #healthcare #business #payers

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📣 Wake-Up Call for Physicians! 📣 While we were immersed in our daily routines, a significant shift occurred in the healthcare landscape. Here’s a snapshot of the Producer Price Index (PPI) for hospitals and physicians from 2007 to 2024. 📊 The graph paints a clear picture: the lion’s share of the excessive healthcare expenditure 💰 was claimed by hospitals, not physicians. But that’s not the whole story. Dig a little deeper and you’ll find that a substantial portion of the hospital funds (not shown in this graph) were channeled into administrative bureaucracy. 🏥📑 We’re at a pivotal moment in healthcare. It’s time for us to take note, engage in meaningful discussions, and drive change. I’d love to hear your thoughts on this. Let’s start a conversation! 💬 Graph created from Producer Price Index (PPI) data published by US Dept of Labor #Healthcare #Physicians #Hospitals #HealthcareExpenditure #PPI

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Now that the health plans have all submitted their Medicare Advantage bids for the 2025 calendar year, I thought it would be worth bringing up a recognized problem in the CMS Benchmark calculation (United States Per Capita Cost or USPCC) that falsely lowers the benchmark. If you aren’t familiar with how these benchmarks are calculated, I wrote a simplified explanation last month which you can find here: https://lnkd.in/gSmvq9mB The first step in calculating this benchmark is for CMS to add up the risk-adjusted monthly total fee-for-service spend for all Traditional Medicare beneficiaries and get an average spend per beneficiary per month. The thing is, they include beneficiaries that only have Part A (institutional expenses) but not Part B (professional expenses) as well as those that only have Part B and not Part A. Obviously, that means they’re counting people where a meaningful portion of their medical expenditures are not included as if they’re the same as people where all of their spend is included. In effect, this lowers the average monthly cost per beneficiary. Yet, this is the benchmark that is used to represent the cost to manage the combination of all Part A and Part B expenses for a population. That is, the MA bids have to cover both Parts A and B for their whole population but it is being compared to a benchmark where some of the people only have one or the other. Even MedPAC has recognized this issue and calculated in 2017 that if they were to only include beneficiaries with both Parts A and B, it would raise the benchmarks by about 1%. This fact tends to be ignored in the news articles decrying the higher spending in MA when compared to Traditional Medicare. #MA #MedicareAdvantage #Benchmarks #ManagedCare #Medicare

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By: Don Self, CMCS, CPC, CASA          Karlene Dittrich, CBCS, CPC, CPMA, CECCS         Chris Chapman, CPC, CPMA     Is Your Practice Or Organization Receiving Negative Financially Impacted UHC Responses? , Please  Read Below and Complete Our Short Survey.  The aggregated survey results will be posted on Don's list serve   After listening to the Senate Finance Committee hearing May 1st with testimony by Andrew Witty, CEO of UHG, it was clear that the US Senate & House members DO NOT HAVE A FACTUAL UNDERSTANDING OF UNDISCLOSED ACTS BEING TAKEN BY UHC.   We believe some statements by Mr. Witty to be misleading in nature, especially when considering facts posing financial risk to healthcare organizations.  Mr. Witty said that UHG is doing everything to help physicians, clinics and hospitals and that at no point has UHG or its companies  tried to take advantage of its own cyber attack. He stated that claims are processing implying claims payments are being made but failed to disclose  the relevant denial tactics being applied to the processed claims.  However, we have already observed since the Feb 21 attack, an increase in clients reaching out to us due to "post-payment" medical record requests, refund demands & recoupments/offsets and extrapolation attempts from UHC being received by clinics across the USA, that appear to FAIL to meet compliance with applicable state and federal laws. This is HUGE & the committee seems unaware of such detrimental undisclosed financial acts being intentionally exercised by UHC.  As advocates, we would like to show Congressional members proof in numbers of what is really happening, however WE NEED YOUR HELP to report the magnitude of UHC's attempts to recoup or "claw-back" money (patient benefits) previously paid on claims.   If you received one or more Refund Demand/Overpayment notices, recoupment(s) or offset(s), extrapolation notifications  or "post payment" medical record requests, please help us inform the Senate Finance Committee what is really going on by filling out the short survey in the link below.  The data needs to be close estimates. We are not asking for any PHI, or copies of documents or evidence, yet  Your responses will be confidential and only shared with  us & the committee (without the name of your organization).  Also, please provide us contact information & impacted locations in case we need to reach back out to you.  Please at least include the city/states so that we can provide the Senate Committee with geographically accurate reports.  If the Senate Committee wants to see actual examples or evidence, we will reach out to you with info you can get in touch with them directly.   Short and Optional Survey  https://lnkd.in/gGKhKr2A     The May 1st  recording is available at: https://lnkd.in/g_CaZ-vy    

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Physicians face a looming pay cut again next year as CMS proposes to cut the conversion factor for the 5th straight year in 2025! But there's a potential silver lining for ACO participants. CMS is proposing a new advance payment system to reward high-performing providers. This could transform how providers, especially safety-net providers invest in clinical care. Here's how it works: ☑ Early Shared Savings ↳ High-performing ACOs can claim a share of savings early. ↳ This provides immediate financial relief. ↳ Encourages investment in clinical improvements. ☑ Boost for Safety-Net Providers ↳ Targets providers with limited resources. ↳ Enables them to join ACOs and share in savings. ↳ Promotes more comprehensive patient care. ☑ Whole-Person Care ↳ Funds can cover hearing, vision, and dental care. ↳ Supports behavioral health and social determinants. ↳ Integrates various aspects of patient well-being. ☑ Operational Improvements ↳ Advance payments to support hiring and improved operations. ↳ Enhances care coordination and preventive measures. ↳ Aims to reduce hospitalizations and associated costs. _This is the story they are selling but tough to buy given the 5 straight years of cuts to professional services._ ☑ CMS's Funding Approach ↳ Funded by reallocating existing Medicare savings. ↳ Savings generated from reduced hospitalizations and efficient care. ↳ Reinforces the focus on cost-effective healthcare. ☑ Measuring Cost Savings ↳ CMS will track healthcare spending and hospital admissions. ↳ Detailed reports will analyze savings from ACOs. ↳ Benchmarks and performance metrics will gauge success. ☑ CMS's Long-Term Goals ↳ CMS wants all Medicare beneficiaries in value-based care by 2030. ↳ This proposal could reverse the trend of dwindling provider ACO participation. ↳ Focuses on improving health equity and cost management. Will this policy reshape Medicare ACO participation and improve patient outcomes? Time will tell. But a point of contrast from years' past is increasingly health systems have built or bought the capabilities necessary for success in these programs. And all of this occurs in a background of increasing frustration on the part of lawmakers with the dismal results of the experiments emerging from the Center for Medicare and Medicaid Innovation (CMMI). Congress also has grown intolerant of years of annual Medicare cuts for professional services. This has prompted consideration of a wider-scale overhaul to reimbursement under the program for US seniors. How do you think this advance payment approach will impact providers? Another dud or something worth paying attention to?

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