Greg Bauer

HSG Advisors Dashboard is changing the game for healthcare leaders. It provides information they've never had access to and makes it actionable so leaders can make informed decisions about competitor dynamics, service line growth, access point strategies, and much more! Ready to see a demo? Set up a time on my calendar. https://lnkd.in/gAvyUkny #healthcareconsulting #healthcareleaders #hospital #hsgdashboard #healthsystem #claimsdataanalytics

8

2 Comments

Lately, it seems there's a lot of worry about artificial intelligence replacing doctors. According to Penn Medicine, University of Pennsylvania Health System CEO, Kevin Mahoney, that won't be happening. In our latest #HumanizingHealthcare discussion, Kevin shares insights on how Penn Medicine is leading the way in groundbreaking innovations expected to transform patient care and caregiver well-being, such as: ✅ Automating repetitive tasks with artificial intelligence ✅ Pioneering mRNA Technology: ✅ Immune Profiling for Personalized Care: ✅ Expanding home-based care & Telemedicine 🎧 Listen to the full episode, powered by Fidelum Health and Planetree, here: https://lnkd.in/gepA53Hq #HealthcareInnovation, #ProviderFriendly, #StaffEngagement, #PatientExperience, #ArtificialIntelligence, #PersonCenteredCare, Summer Freeman, Michael G., Mandy Kilmartin, FPCC

59

4 Comments

Really good research from Healthcare Growth Partners showing a likely overcorrection in #HealthIT valuations since 2021 as the Fed shifted to a Quantitative Tightening policy. To oversimplify... we got accustomed to having easy access to capital without excessive inflation for so long, that when things got a little tighter they 'felt' a lot tighter, and we overreacted. The monetary base is still high and Health IT valuations should rebound to reflect that. Agree/Disagree? https://lnkd.in/eEq-brHp

13

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

31

2 Comments

Many payers are desperate to tie their payments to something reasonable instead of accepting double digit trends in spending. What about using % of Medicare? --- Milliman released a new whitepaper (in the comments) about how payers can use Medicare prices as a benchmark. This strategy has been becoming more popular as #HealthcareCosts have continued to grow well above inflation for many years. Payers want some kind of strategy to contain that cost, so they're turning to Medicare as a trusted benchmark for reasonable reimbursement to providers (plus some extra % to keep providers content). --- Doing this isn't as straightforward as "just price everything to 150% of Medicare" There are lots of details to consider such as: -Geographic area -Your line of business -What to do about services that Medicare doesn't cover (e.g. reproductive health) or denied claims -How to include non-FFS claims like those in value-based arrangements (see attached image for capitation) --- I've continued to hear about this strategy more often in articles and podcasts the last few years. Many #payers contain their costs by reimbursing based on a percent of Medicare benchmark. But how can others do that at scale? This whitepaper can offer guidance on how to get started. Charlie Mills, Jennifer Gerstorff, Jerry Li, and Lance Anderson #EmployeeBenefits

14

6 Comments

Many payers are using percentage of Medicare to tie their payments to something more stable rather than accepting double digit trends every year. But what's a good benchmark for % of Medicare? --- Milliman released a whitepaper (in the comments) about commercial medical payment benchmarks represented as a percentage of Medicare. This strategy has been becoming more popular as #HealthcareCosts have continued to grow well above inflation for many years. Payers want some kind of strategy to contain that cost, so they're turning to Medicare as a trusted benchmark for reasonable reimbursement to providers (plus some extra % to keep providers content). --- The attached image gives an idea of how much commercial plans are paying relative to Medicare =190% of Medicare overall. Percentage of Medicare FFS rates is one of the most widely accepted commercial reimbursement benchmarks when evaluating provider reimbursement and comparing contracts in the healthcare industry because it adjusts for the mix of services across providers and plans while removing impacts from billed charges, which can vary widely across providers and areas. However, there are factors that can cause the output to vary significantly such as: -Geographic area -Type and granularity of service The whitepaper includes an interactive dashboard to compare different states and types of service. As an example of the variation by geography, for outpatient services the highest and lowest % of Medicare are: -396% in West Virginia -157% in Alabama That's a significant difference --- I've continued to hear about this strategy more often in articles and podcasts the last few years. Many #payers contain their costs by reimbursing based on a percent of Medicare. This whitepaper adds to the discussion the benchmarks for types of services and individual states. How is your plan doing compared to Medicare to cover your #EmployeeBenefits? Spencer Marshall, FSA, MAAA Danjie Zhou, ASA, MAAA Casey Anderson, FSA, MAAA Charlie Mills

23

2 Comments

Medicare-Negotiated #Drugs May Not Get Favorable Coverage In Part D: Will CMS Intervene? Some highlights on #PBM formulary strategies from my recent #IRA webinar https://drugch.nl/3TWOcj4

58

6 Comments

Adding to the #benefits craziness, did you fully understand what just happened in Michigan for GLP-1 coverage? See the post from #epcouncil.org as it illustrates why you have to fully read what is going on along with who may be effected as a plan sponsor or employee member. Focusing on short-term issues without a long-term #strategicplan gets a #fiduciary in trouble.

1

The digital health market showed signs of resilience in Q1'24, despite the broader venture capital slowdown. This quarter was a brighter spot for the industry, indicating a potential shift towards growth and innovation. For a deep dive into the latest trends, investment patterns, and emerging opportunities in digital health, check out this comprehensive report. #DigitalHealth #HealthcareInnovation #VentureCapital #HealthTech #StartupInsights

3

1 Comment

Are you ready to stay the course, even when the finish line keeps moving? I want to share a story about a journey that took nearly two decades to complete. I represented a group of New York hospitals facing a complex Medicare payment issue. Our strategy required us to pivot between regulatory and legislative avenues multiple times, highlighting the importance of adaptability in any long-term plan. It took: ✅Patience ✅Tenacity ✅And unwavering confidence In our evolving strategy to ultimately succeed after 20 years. Remember, real change takes time. But with a resilient mindset, you can navigate any challenge and achieve your objectives. Stay confident and adaptable in your pursuits! #PersistencePays #LeadershipLessons #StrategicPlanning #AdaptAndOvercome

9

Across the healthcare industry, inpatient denial claims are skyrocketing - and inflation is decimating providers’ financial stability. According to a recent report from Becker’s Hospital Review, the final denial rate on inpatient claims increased by a staggering 51% between 2021 and 2023 alone. This surge in denials is concerning for several reasons. Not only does it drain $1.2 billion in revenue that hospitals and health systems rely on to provide care to their communities, but it also means that hospitals are spending more money and resources to appeal these denials. The increase in initial denials on inpatient claims for prior authorization and precertification errors is particularly alarming. These errors rose by 26% from 2021 to 2023, adding to the financial burden faced by healthcare providers. As providers navigate these challenges, companies like No Surprise Bill must advocate for a fairer system that prioritizes patient care over profits. I encourage you to read the full report for more insights into this critical issue - click the link in the comments below to learn more.

23

1 Comment

In the PBM landscape, pricing often appears similar across the board. However, the real value differentiator lies in how PBMs manage clinical programs. Effective clinical management not only drives cost savings but also ensures optimal patient outcomes. It’s essential to look beyond pricing and focus on the quality of clinical programs when evaluating PBMs. 💊💡 #PBM #TransparentRx #ClinicalManagement #PatientOutcomes #PharmacyBenefits

4

An Outpatient Clinical Documentation Improvement (CDI) program offers substantial advantages to healthcare organizations by elevating patient care and operational efficiency. By integrating risk stratification with chronic conditions, enhancing quality measures, addressing social determinants of health, and establishing a collaborative team empowered by technology, such strategic initiatives result in improved patient outcomes and streamlined operations.

3

Provider, payer contract disputes are heating up. "Contract negotiations are growing more contentious between providers and payers as both sides battle rising costs. Fueling the tension are persistent economic challenges stemming from the COVID-19 pandemic. Providers are facing higher costs for labor, supplies and pharmaceuticals. In addition, they are fed up with increased payer denials and years of low reimbursement rates, and in some cases, are choosing to cancel contracts altogether. Payers are seeing their medical costs rise as patients seek deferred care and providers charge more to deliver those services. Payers and providers negotiate for a variety of health plans, including commercial coverage and the government-led Medicaid and Medicare programs, to set reimbursement rates and determine any supplemental benefits for members." It will be interesting to see the headlines over the next 12 - 18 months as price transparency (www.pricetransparency.com) sheds more light on negotiated rates. https://lnkd.in/eunaUuwz

15

3 Comments

What am I missing? Another doomed to repeat, Sellers Be Cautious So it goes n8 The argument for: an insurance company can pay their affiliated medical groups more to capture more of the premium and pharmacy rebates and artificially inflate the MLR to avoid rebates. The argument against this: this strategy may be working at one company that has been in the business for decades, but the PE model does not have a great track record in recent years #physicians #healthinsurance #healthsystems #hospitals

23

3 Comments

Kramer Compounds helps patients gain access to the personalized medications their doctors prescribe. As personalized medicine continues to grow, compounding is a key ingredient in the recipe for success. #pharmacy #compounding #personalizedmedicine

1

In any #patientexperience scenario, ACCESS is number one. Agree? You're the Chief Marketing Officer at any health system USA. Your C-suite just signed a deal with private equity to move primary care to concierge medicine. Your charge is to drive conversions for people to pay $2000 to $4000+ for prime access to a physician. As CMO, you do what you are told to do. Your target audience is easy. People with the means to pay extra. In any region or location, you know who they are. Tracking and measurement is simple, too. The CFO will know how to validate this ROI. The bigger question...is this trend to shore up and protect traditional primary care the right thing to do? * Will it improve access? No * Will it lessen consumer demand for physicians? No * Does it solve health equity issues? No * Is it about 'health' or chronic disease management? No * Are patients the priority? No. They are directed to other options and urgent care if they can't afford the concierge deal. * Does it sound more like socialized medicine? Yes. (e.g. - in the UK, you can buy individual private insurance while the masses are left to the government's cumbersome national health plan.) * The 'haves' vs. the 'have nots' continues to grow? Yes * Does the provider really make any revenue? ?? * Do private equity firms fill their coffers? Yes * Do the comments in the article make you cringe? Yes, yes! As I've reported previously, the patient experience is suffering. We all talk the latest good game to solve the problem. Is this the answer? #healthcare #hospitals #primarycare #physicians #patients

14

2 Comments