Amar A. Desai, MD, MPH

Great commentary and details to be considered from post by Deborah Williams Too few probably understand what you've posted, the other major part of the problem. Commercial insured populations (employers & employees) pay the price for government policy failures that represent major hits on company bottom lines or lead to more individual bankruptcies today. #employeebenefits #employers #commerialinsurance #epcouncil.org

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CVS Health's CFO made a striking confession: "The goal next year is margin over membership". He then explicitly acknowledged the potential loss of up to 10% of their Medicare members to bolster financial margins. What does this mean? In plain terms, one of America's largest healthcare giants, with projected annual revenues nearing $360 billion (still 10% more than last year), is considering reducing its patient base—yes, **patients** (aka members)—under its #MedicareAdvantage plans. This decision comes as a result of growing "utilization pressures"- a payer euphemism indicating that more people are seeking the care they desperately need. And what were those "utilization pressures"? Increased outpatient services, outpatient pharmacy, and behavioral mental health services (healthcare). Big Picture: CVS Health isn’t just any company. It's a behemoth with sprawling operations, including Aetna, a CVS Health Company (a major insurer), CVS Caremark (a leading pharmacy benefit manager), and a vast healthcare workforce through CVS MinuteClinic and Oak Street Health. Despite these extensive resources and their near-monopolistic vertical in the healthcare industry, the focus turns to profits over patients (aka margins over members). The Problem: Incentives. Medicare Advantage insurers and administrators love the upfront capital from Centers for Medicare & Medicaid Services (aka taxpayers), but really dislike it when patients actually need to use their services (which drains their capital) or CMS cuts their reimbursement due to quality concerns. To maintain profitability, they have three options: 1) shed members or 2) make it even more difficulty for patients to use services or 3) all of the above. And here's the problem, all options are bad for patients. Folks, it's beyond time to question the incentives embedded within our profit-drive health insurance system and in Medicare Advantage. We have to critically evaluate how business decisions by CVS (or United Healthcare or Humana) ultimately affect patient outcomes and #provider practice. To be clear, margins are necessary because it's true "no margin, no mission", but when a company can openly prioritize margins with potential repercussions for vulnerable, senior populations, it highlights the profound misalignments between healthcare needs and business strategies. #Healthcare #CVS #MedicareAdvantage #BusinessEthics #PatientCare ABIG Health Matthew Raffa MBA Meroka UNC Kenan-Flagler Business School MBA@UNC ESCP Business School

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Aetna plans to automate 30% of its utilization management (UM) requests by the end of the year. What are the potential benefits and drawbacks of this decision? Utilization Management (UM): UM ensures patients receive the right care and in the most cost-effective setting. This involves reviewing requests to determine if they are medically necessary and covered by the plan. Automation in UM involves Augmented Intelligence and machine learning algorithms to process UM requests. These systems analyze patient data, medical guidelines, and historical claims information to make decisions about coverage. 1. Increases Efficiency: Automating UM processes can significantly reduce the time it takes to review and approve requests. AI algorithms can process large volumes of data much faster than humans, leading to quicker decisions. This means patients experience shorter wait times for treatments and procedures, improving patient satisfaction and potentially leading to better health outcomes. 2. Reduces Costs: Automation can reduce administrative costs associated with manual UM process. This leads to savings in overhead expenses. These cost savings can be passed on to consumers through lower premiums or to healthcare providers through higher reimbursement rates. 3. Accuracy and Consistency: Automated systems are less prone to human error and bias. They apply pre-defined rules and algorithms consistently, ensuring all requests are evaluated fairly and objectively. This leads to more accurate decisions about coverage, reducing the likelihood of denials based on subjective interpretations of medical necessity. Possible Cons: 1.Potential Errors and Bias: While designed to be objective, AI algorithms are only as good as the data they are trained on. If the training data reflects existing biases in the healthcare system, the automated system may perpetuate those biases, leading to unfair or inaccurate decisions. This could result in certain demographics with specific conditions being unfairly denied coverage or facing unnecessary delays in treatment. 2. Lack of Human Oversight: Automating UM processes may remove the human element from decision-making. While efficient, this can lead to a lack of understanding in cases with complex medical or social factors.Patients may feel unheard or misunderstood if their cases are handled solely by an algorithm, potentially leading to dissatisfaction and distrust in healthcare systems Automating 30% of UM requests presents opportunities and challenges. While it has the potential to increase efficiency, reduce costs, and improve accuracy, it's crucial to address complex concerns. Aetna should ensure diverse and unbiased training data for their AI algorithms to minimize bias and ensure equitable coverage decisions. Keep human oversight in the process, particularly for complex cases. Invest in retraining and upskilling programs for employees whose roles are impacted by automation, prepare them for the evolving landscape.

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The California SNF Workforce & Quality Incentive Program (WQIP) incentivizes facilities to improve quality of care, advance equity in healthcare outcomes and invest in workforce. SHP utilizes the program domains and measurement areas to estimate potential incentive payments based on a number of factors, including MDS data, CMS data releases, previous year cost reporting and survey health deficiencies. SHP’s WQIP report displays the data at a high-level view for each facility in your corporate portfolio, as well as providing greater drilldown detail for represented domains and measures. Schedule a free demo today to learn more. https://okt.to/rfxNPs #cawqip #skillednursing #intellilogix #shp

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Walmart announced the closing of its #healthclinics and #virtualhealth business today, citing #staffing challenges and #financialpressures. #Primarycare is among the least #profitable tiers in the #healthcaresupplychain. Most #healthsystems invest in primary care as a #strategy to secure more lucrative #downstream #referrals to their #specialists and #tertiarycare #hospitals. Walmart obviously lacked these revenue capture opportunities. In my view, this should not be viewed as a signal that the #retailmedicine model is unsustainable, but rather that it likely requires better integration and collaboration among #traditional and #nontraditional #providers. My colleagues Claudia Rosales and Andrew Balthrop wrote about some of the cost and staffing pressures that face providers in our white paper on inflation. I will place a link in the comments if you are interested! #supplychainu J.B. Hunt Transport Department of Supply Chain Management at the University of Arkansas

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The healthcare landscape is undergoing a seismic shift, driven by vertical consolidation led by insurance giants. A recent perspective in the New England Journal of Medicine highlights this trend and its far-reaching implications for patients, physicians, and the entire healthcare system. Key points to consider: 🏢 Vertical Consolidation: Major insurers like UnitedHealth Group, Humana, and CVS are rapidly acquiring physician practices and care-delivery companies. This has resulted in over 50% of Medicare beneficiaries now enrolled in Medicare Advantage plans. 💰 Financial Scale: The government will pay approximately $500 billion to insurance companies in 2024 alone to administer Medicare Advantage programs. 🚑 Patient Impact: This consolidation poses significant risks to patient care. Insurers can deny coverage or discourage use of necessary services, steer patients toward their own services (potentially disrupting longstanding care relationships), and replace physicians with lower-cost clinicians. 📈 Cost Inflation: In Medicare Advantage, abuse of risk adjustment accounts for $54 billion in overspending per year compared to traditional Medicare. 👨‍⚕️ Physician Autonomy: Corporate ownership promises to unburden physicians from administrative tasks, but it may be a Faustian bargain. Insurers can dictate staffing, scheduling, and patient visit durations, potentially compromising care quality. America's complex health care system in an "object in motion" with sizeable inertia- without intervention, it will continue on its current path. The status quo has a predictable outcome: a healthcare system increasingly controlled by a handful of insurance conglomerates, potentially at the expense of patient care and physician autonomy. Changing course will require intentionality and energy. The article suggests several policy approaches: 1. 🔍 Strengthening antitrust scrutiny 2. 🚫 Limiting vertical integration of insurance companies 3. 📜 Revitalizing corporate practice of medicine laws 4. 📊 Enhancing medical loss ratio regulations and closing loopholes As healthcare professionals, policymakers, and concerned citizens, we must actively engage advocate for reform. The future of our healthcare system - and the quality of care available to patients when they need it most - depends on the actions we take today. What are your thoughts on this trend? How can we work to ensure a healthcare system that prioritizes patient care and physician autonomy over share holders? #HealthcarePolicy #MedicareAdvantage #VerticalIntegration #HealthcareReform

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Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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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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The latest news, are you aware? Vertical integration struggling in healthcare now demonstrated by the just announced CVS Health cost-cutting efforts. #employers need to stay aware and determine such impacts on their benefit design, plan offerings, and partners in executing a successful benefit program. #epcouncil.org

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Listen to Mary Beth Lang share insights on Risant Health's strategy of bringing Value Based Care & Coverage (tools, technology and services) to network model healthcare systems like Geisinger Health. Don't miss out on this opportunity to learn how working together; medical facilities and clinicians can better manage costs, utilization, eliminate unwarranted clinical variation, and reduce redundancies and inefficiencies to improve the patient experience and healthcare outcomes! #ValueBasedCare #Healthcare #PatientExperience https://lnkd.in/eRE79CyA

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MA: The "STAR" of the show. Silly me, given my recent articles on benchmarking and bidding in Medicare Advantage (MA) as well as the recent stargate fiasco that is happening this year, I thought I’d write a brief article that explains the basics around the star ratings. Well, just like those other topics, the details are super complicated and confusing. 2024 Star Ratings represent services provided in 2022, but don’t impact payments until 2025 and the technical notes include words and phrases like “clustering,” “relative distribution” and “Tukey outer fence outlier deletion.” So instead of a superficial overview, I am making the mistake of taking a deep dive into Star Ratings. I apologize in advance for pulling you down this rabbit hole with me. Given the extent of the information, I’m choosing to start off by sharing it in bite sized pieces and will then post the whole thing in its entirety once I’m finished. Let's start off with...Why do we even have Star Ratings? As you know, in Medicare Advantage, private health plans are paid a fixed monthly amount for each of the Medicare beneficiaries that are signed up with their plan. Given the number of options an individual beneficiary may have to choose from, CMS wanted to help them choose the best plan for them and not just incentivize plans to provide high quality care, but to facilitate growth in the best performers. At a high level, the Star Rating system has two impacts: a guide to consumers choosing among MA plans and as a factor in determining MA plan payments. It is important to remember that there is no real quality data for Traditional Medicare, so star ratings only enable comparisons between MA plans and not between MA and Traditional FFS Medicare. #MA #Medicare #Stars #Tukey

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