Partnership to Empower Physician-Led Care’s Post

Value-based models continue to fail. why? for many reasons but one of the root causes is the philosophy is that these models shift more risk to the providers. think about how much risk physicians already bear. then to put all of the financial risk on the providers through VBC is not just a bad idea, but lacks fairness, transparency, and is likely doomed to fail - at the cost of our healthcare system and patient lives.

Current CMS MSK value-based models like BCPI and CJR are likely going away (and taking their middling levels of success with them). However, with the goal of having all beneficiaries in some form of accountable care, the expectation is that they will be replaced by...something. We're still waiting for CMMI to detail what that something will be. There have been hints that the focus will be on care coordination between specialists and PCPs -- for instance, the Making Care Primary model announced last year. Per the AAHKS 2024 Winter Update Newsletter, CMMI may formally propose a new "Specialty Care Episode Payment Model" as an evolution of prior VBC programs. The new model is expected to contain the following elements: 1. Specialist outcome data to help inform PCP referrals 2. E-consults and enhanced referrals to improve access and reduce wait times 3. Capitated payments to specialists for chronic care management 4. Condition and procedure-based spending targets to facilitate longitudinal care If in fact such a model is announced, it could further the sea change in how specialists are incentivized to deliver care. While some might see this as a threat, the smart money is on getting out in front of these changes and embracing the evolving care model. Interestingly, many of these elements dovetail with efforts to weave digital platforms into MSK care. The time for collaboration, not competition, seems nigh. Similarly, healthcare organizations will benefit from creating efficient, effective processes that link MSK specialists and PCPs -- not middlemen but bridge builders. Can CMS/CMMI hit on the right mixture of aligned incentives, care coordination, and clinical integration to make value-based MSK care a success? We may soon find out. #medicine #healthcare #msk #health #healthcareinnovation #vbc #valuebasedcare #healthtech #digitalhealth #healthcaretechnology

Check out Carrie Nixon's post below on the newly proposed Advanced Primary Care Management Codes from the 2025 Medicare Physician Fee Schedule Proposed Rule! #CMS #caremanagement #digitalhealth #healthcareinnovation

Carefully consider this proposal and tie through related to VBP transitions and AI tools.

We run savings, centers of excellence/dysfuntion, ROI analyses all the time. In a nutshell, this one shows: ✔️ 1,696 enrolled EEs ✔️ 3,754 shoppable medical claims ✔️ 2,009 or 53% of those medical claims are over-priced (based on in-network paid claims) In a live demo I can show: 👉🏻 how communication and other factors impact the potential savings. 👉🏻 drill down into specific procedure groups 👉🏻 The one for this group showed only 33% of all medical claims where members are accessing care have superior health outcomes. (based on in-network claims) We can design and implement curated communications to members in specific areas to highlight providers and facilities in their network to achieve member and plan savings with better health outcomes. This group also has $1.2M+ in Rx overspend (or said another way, potential savings opportunity), even accounting for rebates and other cost management programs. We expect to capture at least 10% of that overspend, which is $126,511. We expect to successfully move between both medical and Rx claims within their network and formulary to get members to better priced care with better health outcomes resulting in an annual savings of $175,205 after accounting for PEPM and paid rewards. Without changing their plan, their network or their formulary. We help members use their existing benefits better. ROI is 2.57

As always, intriguing insights from Benjamin Schwartz, MD, MBA. Seems very likely that it's not a question of if, but when, new value-based payment models will emerge within the MSK space. Hopefully, CMMI will successfully iron out some of the wrinkles that have hampered the potential for long-term success in prior programs like CJR and BPCI. #valuebasedcare #healthcareinnovation

Aligning Utilization Management (UM) with Clinical Documentation Improvement (CDI) is crucial for optimizing both financial performance and patient care outcomes. UM ensures that hospital resources are used effectively, controlling costs and enhancing patient care. CDI focuses on accurate documentation, ensuring illnesses' severity and complexity are properly recorded. This supports precise coding, billing, and clinical accuracy, which are vital for patient care and reimbursement. The synergy between UM and CDI is key to operational efficiency and clinical excellence. UM identifies areas for resource improvement, while CDI documents these insights, reflecting patient conditions accurately. This collaborative approach enhances financial metrics and clinical outcomes by promoting accurate diagnosis and treatment planning. Aligning UM and CDI optimizes patient care and operational efficiency. By integrating these functions strategically, healthcare organizations can navigate complexities confidently, delivering superior care outcomes while maintaining financial viability. https://lnkd.in/dkwGy85z #healthcareconsulting #casemanagement #carecoordination #utilizationreview #patientcare #healthcarequality #valuebasedcare #healthcarestrategy #medicalguidance #denialsprevention #denialsmanagement #utilizationmanagement

Hey all! As promised, we've posted a more in-depth article focused on the new Advanced Primary Care Management codes proposed in the 2025 Medicare Physician Fee Schedule Proposed Rule that was released by #CMS last week. (Was it only last week?? Feels like a lifetime ago...) Headlines: * The new monthly APCM codes are NOT based on time spent by practitioners or clinical staff, opening the door for use of AI tech to automate certain care coordination/management functions. * The codes provide a reimbursement opportunity where time requirements for CCM/PCM are not met. * The APCM codes are another step towards preparing primary care physicians for the shift to value-based care -- BUT, proposed reimbursement rates combined with requirements for implementation could hamper adoption. Please share your thoughts in the comments when you have a moment! I also strongly encourage all stakeholders -- vendors of care management services, PCP practices, etc. -- to submit comments to the Proposed Rule by no later than September 9th. We've seen CMS reference specific comments in their Final Rule as reason for changes to their original proposal. We're happy to help! https://lnkd.in/eV4CxPmg

In response to the recent report from the Medical Group Management Association (MGMA), it’s evident that the prior authorization process remains a significant challenge for medical groups, impacting patient care and straining operational efficiency. The report highlights the pressing concerns around the prior authorization burden faced by medical groups, including delays, denials, and resource reallocation due to the surge in prior authorization requests. Key Takeaways from the MGMA Report: Widespread Impact: 89% of medical groups find prior authorization extremely burdensome, affecting practices of all sizes, with 97% reporting patient care delays or denials. Operational Challenges: 92% of practices have adjusted staffing due to increased prior authorization requests, signifying a considerable administrative burden. Top Challenges: Delays in authorization decisions (88%), prior authorizations for routinely approved items and services (83%), and inconsistent payer policies (80%) are identified as major obstacles. Continue reading here to discover how Health Plans and PBMs can address the prior authorization burden: https://lnkd.in/g8Uvdx6k #priorauthorization #pbms #healthplans #priorauth #healthcareIT

The latest release from CMS delineates a series of impactful changes and updates, of which the most striking is the decrease in the conversion factor, now set at $32.74—a change that represents a 3.4% decrease from the previous year and one that will undoubtedly influence the budgeting strategies for rehabilitation practices. The updated policy also sheds light on the revised therapy threshold, now requiring the application of the KX modifier beyond the $2,330 mark, a detail that requires attention for compliance and billing accuracy. In addition to these financial adjustments, CMS has introduced a new threshold for targeted medical review, setting it at $3,000 through 2027, with subsequent annual updates tied to the Medicare Economic Index, a change that suggests a long-term strategy for monitoring and managing therapy costs. The document further ventures into the domain of supervision regulations, with the 2024 final rule permitting the use of general supervision for RTM services, an adaptation that reflects the growing integration of technology in therapeutic practices. Alongside these alterations, the introduction of new CPT codes for caregiver training represents a forward-thinking approach to inclusive patient care, broadening the scope of billable services to recognize the essential role caregivers play in the continuity of care and patient outcomes. In this time of change, Net Health stands as a sentinel, with our team working tirelessly to ensure that our software and services are ahead of these changes. Our goal is to predict and adapt to these industry shifts, equipping clinics with the foresight and tools needed to navigate the future of healthcare confidently.