Kevin McDonald

Risk adjustment and quality reporting are evolving. Standard formats. Interoperability. New sources of data. AI. Result- claims-based risk capture will play less of a role. Great article for some insights into the potential future for those that have not read/seen it yet.

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Something to consider for #vbc: The average Medicare beneficiary sees two specialists, and 30% of beneficiaries see five or more(!). Managing VBC contracts with multiple providers and overlapping episodes can be complex (think a pregnant woman with diabetes, a diabetic/CHF patient undergoing hip replacement). Some helpful ideas in the blog here (e.g. the importance of provider transparency), but of course, it's all about the specifics of your situation.

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Major Changes Coming For The KC Market 📢 Blue KC to Exit Medicare Advantage Market by 2025 Due to Regulatory Demands 📢 Blue Cross and Blue Shield of Kansas City (Blue KC) has announced its departure from the Medicare Advantage (MA) market by the end of 2024, citing increased regulatory demands and financial pressures as primary reasons for the decision. The company will shift its focus to employer-sponsored health plans, Medicare supplement plans, and Affordable Care Act plans while ensuring uninterrupted, quality service to current MA members through 2024. With a smaller MA membership base, Blue KC finds it challenging to compete economically at scale, leading to the difficult but necessary market exit. In a statement, Blue KC's President and CEO, Erin Stucky, expressed disappointment, saying, “We explored every alternative path for our MA members and are disappointed we must exit this line of business.” This move aligns with industry trends, as other insurers, like Oscar Health, have also exited the MA market due to similar challenges, including the impact of regulatory changes such as the CMS's benchmark payment adjustments on the profitability of MA plans for smaller insurers. #Healthcare #MedicareAdvantage #BlueKC #RegulatoryChallenges #InsuranceIndustry #HealthPlans #CMS #MarketExit

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The clinical dashboard is a key aspect to ensure strong patient care and streamlined operations for providers. Not only is the data important, but the insights are what really makes the difference for both parties. I enjoyed speaking with Skilled Nursing News about what needs to be included in the dashboard, and the overall impact this type of technology can have on the entire healthcare system. Thanks again for the opportunity!

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New Medicare Advantage Quality Ratings Changes are coming! A new calculation will affect how quality ratings are assessed, with the goal for better accuracy and fairness. This of course comes after court findings prompting CMS to take appropriate action. #Medicare #Healthcare #QualityRatings #PayerNews https://shorturl.at/p8y3n

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CMS Proposes Over 4% Cut to Home Health Medicare Payments in 2025: "To rebalance the Patient-Driven Groupings Model (PDGM) and make it budget neutral... CMS is proposing a permanent prospective adjustment to the CY 2025 home health payment rate of -4.067%." Let Bartlett Strategy Group, LLC help you navigate these cuts and ensure that you're maximizing your reimbursement with accurate coding and OASIS outcomes! https://lnkd.in/eTWtJBQG

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The April final rule on #supplementalbenefits in #MedicareAdvantage is a big deal requiring immediate action from #healthplans. The Centers for Medicare & Medicaid Services (#CMS) regulations have 3 major components: evidence, eligibility and member awareness. Beginning with the CY2025 bid process, CMS will deny a plan’s bid if it hasn’t demonstrated that its proposed supplemental benefits for the #chronicallyill (#SSBCI) is reasonably expected to improve or maintain the health or overall function of its chronically ill enrollees. CMS is also implementing annual review of SSBCI offerings for compliance. To comply with the final rule, plans must do the following: ▶️ Establish an evidence-based bibliography of clinical literature for each SSBCI offering, showing it can reasonably improve or maintain the health of chronically ill enrollees. All supporting evidence must be published within 10 years of the coverage year. ▶️ Use written, objective criteria to determine an enrollee’s eligibility for SSBCI, ensuring they meet the definition of “chronically ill enrollee” with complex conditions needing intensive care coordination. MAOs must also document when enrollees are deemed ineligible to ensure equitable access to benefits. ▶️ Include an all-channel disclaimer listing the chronic conditions required for eligibility and clarifying that additional criteria may apply. ▶️ Beginning January 1, 2026, MAOs must send mid-year notifications annually each July to each enrollee with unused supplemental benefits. CMS requires the mid-year notice to support #healthequity and inform enrollees about unused supplemental benefits. These new requirements impose huge new operational challenges for plans under tight deadlines. Get cracking now. Full rule: https://lnkd.in/e8GwBmCq

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Individual insurance markets such as ACA Marketplace (aka Obamacare) and Medicare Advantage have annual regulatory changes that means plans annually evaluate expansion, exiting, or scaling back their footprint. BCBS Kansas City exited the Medicare Advantage market with their 32k members which caused me to think about those scenarios. This is not a post about the impact to the BCBS KC members nor how BCBS KC made the decision since it's a tough one and I have the same view from the balcony as my favorite Muppets, Waldorf and Statler. 𝐇𝐚𝐭𝐞 𝐭𝐡𝐞 𝐆𝐚𝐦𝐞, 𝐧𝐨𝐭 𝐭𝐡𝐞 𝐏𝐥𝐚𝐲𝐞𝐫𝐬: Regulatory and price change is a constant and individual members are making annual decisions. It's more like a cyclone than tail winds and head winds which means plans have to decide their threshold or risk being whipped around by the wind. 𝐊𝐧𝐨𝐰 𝐰𝐡𝐞𝐧 𝐭𝐨 𝐟𝐨𝐥𝐝 𝐭𝐡𝐞𝐦, 𝐤𝐧𝐨𝐰 𝐰𝐡𝐞𝐧 𝐭𝐨 𝐡𝐨𝐥𝐝 𝐭𝐡𝐞𝐦: At some point, the regulatory conditions get more favorable and plans that exited consider re-entering. It's always more costly to re-enter than you think due to acquisition costs, regaining market trust, and you have to offer lower-prices/richer benefits than the plans that stayed. 𝐍𝐞𝐯𝐞𝐫 𝐜𝐨𝐮𝐧𝐭 𝐲𝐨𝐮𝐫 𝐦𝐨𝐧𝐞𝐲 𝐰𝐡𝐢𝐥𝐞 𝐲𝐨𝐮'𝐫𝐞 𝐬𝐢𝐭𝐭𝐢𝐧𝐠 𝐚𝐭 𝐭𝐡𝐞 𝐭𝐚𝐛𝐥𝐞: What about staying in the market and shrinking your service area? There's often regulatory rules against this approach, fixed costs don't go down, and your market will still consider that to be an exit. While this can be an appealing middle ground, it doesn't usually pencil out. Also, I just quoted more Gambler lyrics since it's fun. The opening line doesn't really have anything to do with the commentary. 𝐔𝐩𝐬𝐢𝐝𝐞>𝐃𝐨𝐰𝐧𝐬𝐢𝐝𝐞? This is the only truly helpful information that I am offering. A talented CFO that I worked with drilled into my skull that you also have think of if the upside is greater than the downside for staying in the market. To simply paraphrase, if there's a 50% change of making $1 million, but losing $10 million, well to quote my new favorite song, 𝘛𝘩𝘦𝘳𝘦'𝘭𝘭 𝘣𝘦 𝘵𝘪𝘮𝘦 𝘦𝘯𝘰𝘶𝘨𝘩 𝘧𝘰𝘳 𝘤𝘰𝘶𝘯𝘵𝘪𝘯'/𝘞𝘩𝘦𝘯 𝘵𝘩𝘦 𝘥𝘦𝘢𝘭𝘪𝘯'𝘴 𝘥𝘰𝘯𝘦 https://lnkd.in/gKMjhjGW

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The CMS Innovation Center (CMMI) announced the Transforming Episode Accountability Model, a proposed mandatory episode-based bundled payment model, is slated to begin in January 2026. It is among a list of alternative payment models supporting CMS's goal to have all Medicare beneficiaries in an accountable care relationship by 2030. The five-year model structure marks significant changes from previous versions and reflects how the approach to bundled payments is evolving.

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Discover the Fiduciary Advantage with DisclosedRx – a PBM that prioritizes your clients' best interests. In an industry often marred by hidden fees and cloudy decision-making, DisclosedRx stands out by embracing fiduciary responsibility. We are committed to acting in the best interest of your clients and eliminating conflicts of interest. Experience the transformation of the PBM industry with DisclosedRx. Connect with us here on LinkedIn to learn more about how we can help you navigate the world of PBMs with confidence. #FiduciaryAdvantage #DisclosedRx #PBM #ClientsFirstApproach

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Munzoor Shaikh and I are looking forward to our webinar presentation this week with the HFMA South TX chapter on Value Based Care. The registration link is below: https://lnkd.in/eNtZFSDQ

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The time is now for new business models for virtual care to integrate more fully with existing care or to focus on unmet needs like chronic condition management….

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🔍 Exploring Code G2211: CMS's latest update is revolutionizing primary care coding. Dive into our article to uncover its impact and implications. Read more: https://lnkd.in/et9mZt3U #G2211 #MedicalCoding #PrimaryCare #G2211Update

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OIG ALERT: The first OIG report since February came out on Friday. Not shocking but the findings continue to be consistent with previous reports. If you need help assessing your risk, let me know. The report that came out Friday looked at 2016 and 2017 claims that Independent Health Association submitted to CMS for risk adjustment. The OIG focused on 8 target areas seen to have consistently high false positive rates. In this case they found that 230 of the 247 conditions reviewed, or 93%, did not have documentation to support the conditions submitted. The total takeback for this $646k for the two years. However, if the results were extrapolated, as can be done beginning in 2018, the takeback would have been 10X larger at $7M. The areas reviewed included: -Acute Stroke: 100% incorrectly captured -Acute Heart Attack: 97% incorrectly captured -Embolism: 90% incorrectly captured -Lung Cancer: 100% incorrectly captured -Breast Cancer: 100% incorrectly captured -Colon Cancer: 97% incorrectly captured -Prostate Cancer: 93% incorrectly captured -Miskeyed Diagnoses: 73% incorrectly captured For my followers by now this shouldn't be an earth shattering report. One of our 45 best practices for a strong risk adjustment program is to have stops in place to prevent these claims from going out the door without a review. Stay tuned for more updates and summary stats that aggregate the findings from these OIG reviews. https://lnkd.in/ec2R9C-G

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🗣 HealthSherpa's FFM Reintegration The Centers for Medicare & Medicaid Services (CMS) has issued new guidance on correctly integrating FFM accounts with HealthSherpa for Agents. If you haven't received these instructions, please follow the steps below. 👇 1) Ensure you are logged out of the CMS Enterprise portal. https://lnkd.in/et64YmKf 2) Log in to your HealthSherpa for Agents account. https://lnkd.in/ebsnswFv 3)Navigate to your Settings page and select ‘Remove My FFM Account’ (refer to the screenshot below). 4) Reintegrate your FFM account. For more information on how to reintegrate your FFM account with HealthSherpa, visit this help page.https://https://lnkd.in/eQBJxh5R

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This Thursday the Energy and Commerce Committee will hold a hearing on the Centers of Medicare and Medicaid Improvement (CMMI). Members of the Committee are expected to raise concerns and praise for the agencies' efforts to test and achieve savings in value-based payment models over the years. Since its inception in 2010, CMMI has tested many new payment models including bundled payments, multiple accountable care organization offerings, and the making care primary model. The agency continues to face challenges, such as finding ways to engage rural providers and solo or small physician specialty practices. Reps. Michelle Steel and Susie Lee and Sens. Markwayne Mullin, Kyrsten Sinema and Thom Tillis introduced the EASE Act (HR 7149 / S.4078) to encourage CMMI to create a new payment model for rural and underserved communities to reduce long wait times that many seniors and residents face in these communities when seeking care from a specialist. The bill was developed based on years of data collected and reviewed by OCHIN to help community health centers and rural hospitals improve care integration and create a new value-based payment model. While Congress looks for ways to improve outcomes and reduce costs; and medical schools continue to look for ways to grow the physician workforce, one pathway that would fill the needs of communities (especially rural areas) and prevent avoidable hospital admissions is the EASE Act which looks to utilize telehealth or e-consults to help our most vulnerable populations receive timely care

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Recent court decisions have caused CMS to recalculate Medicare Advantage Star Ratings - which will generate increased bonus payments for some plans as extreme outliers are not discounted from the calculations. But note: this decision was made based on the Administrative Practice Act (a federal law governing how federal agencies do their work) rather than the substance of the action; smart money will expect future rulemaking to comply with the decisions and further modify the calculations. The takeaway for practices and plans is to take the win today but not rest on these decisions: Providers, do your absolute best to deliver the best care, and Plans, invest in practices doing the work with your patients now for long-term success. https://lnkd.in/gSRFcuMs

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