Catherine Bass

On the cusp of Walmart Health closing its clinics and virtual care units, CVS Health reports stocks dropping. This comes after missed revenue estimates, revising down its 2024 guidance, and now expects to raise insurance plan prices in the coming year as it adjusts for Medicare reimbursement cuts. Higher utilization of healthcare services, which means more insurance dollars spent, weighed on the company in addition to Medicare reimbursement rate cuts that will continue to pressure the company for the remainder of the year. Insurers also have been seeing medical costs spike as an increasing number of Medicare Advantage patients return to hospitals to undergo procedures they had delayed during the pandemic. CVS said it expects 2024 earnings per share and cash flow from operations to reduce, with adjusted EPS expected around $7, down from $8.30 previously, and revised cash flow of at least $10.5 billion, compared to the previous $12 billion estimate. Overall, between the Walmart or CVS stories, these are trends we see across the country and puts a spotlight on the approach of large corporations entering healthcare. - Is the investment in mission, prevention, primary care? - Is the complexity of healthcare understood to understand trends? - Are tools for primary and continuity care leveraged over acute care? - Are groups in it for the long haul? Even with new mergers in primary care there is much to be seen how implementation and incorporation will come together. #healthcare #corporateinvestment #healthisprimary

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The article below describes the delicate and complex relationship between payers and providers in the healthcare industry, often likened to a tightrope balancing act. The underlying core is human attitudes and desire for advantage. The winner controls the game afoot. Value-based care attempts to eliminate the oppositional approach and target a win-win for both. It also increases the level of responsibility that needs to be updated in today's FFS marketplace. The good news is that developing technology and analytics, with their proven track record, can improve performance beyond anything that was possible in the past, providing reassurance and confidence in the future of healthcare. The excuses for not transforming health and dental care rapidly decrease, motivating us to embrace change and strive for a better healthcare system.

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“All the research is there that behavioral science works, and what Wellth has done for us is to be that secret sauce for moving that behavior change.” In our latest webinar, Julie Smith, RN, MPH, Vice President of Value Strategy and Clinical Operations at Sanford Health Plan, and Dinesh Joseph Apte ,  Senior Vice President of Growth and Strategy at Wellth, discuss the science behind investing in daily care motivation in order to drive down high-cost utilization, quality ratings- specifically aimed at Medicare Advantage Star Ratings. Watch on-demand: https://lnkd.in/g47J8PUj

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Sharing with First Report Managed Care, “Technology has been the mainstay for tracking and trending patient progress and evaluating value-based care regarding their physical health. The behavioral health community must utilize similar models to receive payments and incentives. An #EHR with specialized behavioral health content, scales, scores, and measurable outcomes is critical to successfully delivering and reimbursing holistic care.” Mary Russell, MJ, BS, RN, #CliniComp’s Senior Director Clinical Implementation. CliniComp prides itself on the seamless display and integration of data throughout a patient’s record due to our ability to adapt and normalize data across disparate systems. Full article https://lnkd.in/g8ZTg-Bm   #PatientCentric #BehavioralHealth #CliniCompSolution #VA #Veterans #PatientCare #Clinicians #HealthcareIT #HealthTech  

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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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Don’t miss the session on May 8, when Erica Galvez, CEO, Manifest MedEx, will join other health data leaders in a discussion, “How Health Information Exchanges and Emerging Health Data Utilities are Leveraging Data to Address Public Health” at AcademyHealth’s Health Data Leadership Institute. Register here to learn more about the value of collaboration and partnerships with public health organizations.  https://lnkd.in/dgNEjZWZ  

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New in the latest issue of Health Plan Weekly: Dems work to cement enhanced ACA subsidies, lessons learned from Medicaid unwinding, study finds "inexcusable" variation in payers' negotiated rates, and more top stories. https://hubs.ly/Q02RnTkK0

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The OIG Semiannual Report to Congress has been released, highlighting insufficient documentation in Medicare Advantage RADV Audits. This issue impacts administrative processes and directly influences patient care quality and the financial stability of health systems nationwide. The report emphasizes the negative economic implications of inaccurate code assignments, focusing on conditions like neoplasms, acute CVA, acute MI, acute pulmonary embolism, major depression disorder, and peripheral vascular disease. Of significant concern are instances where a diagnosis is classified as acute, but the documentation only substantiates a historical or past medical history, underscoring the criticality of accurate code assignments. As change agents, it is not just our duty but our shared responsibility to tackle this issue collectively, involving a diverse group of experts beyond those solely responsible for assigning ICD-10 codes. While practitioners may only be expected to stay updated on some guideline changes, our collective responsibility is to implement the necessary checks and balances for precise code assignment on claims. What steps has your organization taken to combat inaccurate code submissions?

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