Kenneth Poole Jr

Bravo to Kevin Grumbach Deborah Cohen and Yalda Jabbarpour for this piece on #primarycare and the recent trends. "When Walmart, the corporation ranked number one on the Fortune 500 list, cannot achieve a successful business model for primary care, it reveals the root problems of thoroughly inadequate payment for primary care and underestimation of the work of primary care. Corporate and private equity investors—seeking extractive short-term financial returns and not committed to long-term investment—destabilize an already fragile primary care sector. Rapid start-ups and closures of primary care practices add turbulence to forces already buffeting communities dealing with declining access to primary care. The failing experiment of corporate, investor-owned primary care highlights the need for bold public policy to address primary care payment, infrastructure, and corporate ownership." #healthcare #healthcareonlinkedin

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The Medicare Advantage star ratings system is designed to evaluate the quality of Medicare Advantage plans. These ratings range from 1 to 5 stars, with 5 being the highest, and are based on several factors, including customer service, member satisfaction, and health outcomes. Higher star ratings lead to better reimbursement rates from CMS and can help attract more enrollees. UnitedHealthcare’s lawsuit claims that its downgrade was based on a single customer interaction, which could negatively affect its reimbursement and market competitiveness during the open enrollment period https://lnkd.in/erKQy7Ge #MedicareAdvantage #StarRatings #UnitedHealthcare #CMS #HealthcareLawsuit #HealthInsurance #MedicareNews #OpenEnrollment #HealthcareUpdates #MedicareAdvantagePlans #InsuranceRatings #HealthcareFinance #PatientCare #MedicareReform

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Here’s your recap of last week’s health IT news 🗞️ 👇 Notable partnerships 🤝 • WakeMed will roll out AI clinician assistant Regard across three hospitals by the end of the year.    • Saint Luke's Mid America Heart Institute adopted Story Health to support patients with AFib.    • Cone Health, Sentara Health, and A Plus Family HealthCare, along with 2 others are partnering with TytoCare to deliver primary care in local school districts.    • Ballad Health is integrating with teleneurology provider Sevaro to provide stroke care in the ED.    • Sturdy Health is utilizing Notable for appointment scheduling, demographic and insurance verification, and pre-registration form completion.    • Group Health Cooperative of South Central Wisconsin has implemented the Epic-based virtual care platform KeyCare to provide virtual visits nationwide. Product updates 👩🏼‍💻 • Transcarent launched an AI-powered platform for patients to navigate benefits, clinical guidance, and care delivery.    • Epic announced it will launch a new patient data insight tool relying on its Cosmos database.    • LG Electronics released its hospital-at-home platform, PrimeFocus.    • athenahealth released two new specialty care solutions for women’s health and urgent care.    • SmarterDx announced a $50M Series B funding round.    • Kyruus Health has expanded its network to include virtual behavioral health providers.    • Laguna Health released a new performance dashboard that detects metrics such as burnout risk and empathy in patient interactions.    • Crosby Health, which aims to automate claim denial appeals, announced the launch of its large language model and $2.2M in pre-seed funding.    • Radiometer and Etiometry Inc. are partnering to enhance clinical decision making in acute care settings.    • TurningPoint Healthcare Solutions acquired the AI prior authorization vendor Fairway Health.    • Komodo Health announced updates to its MapEnhance product, adding SDoH insights, and two new specialty data partners, GeneDx and COTA. Posts we enjoyed 👏 • We’ve been watching much of the recent news on nurse strikes as well as the political back and forth on AI regulation, and really appreciated Sarah Gebauer, MD’s take on AI governance: https://lnkd.in/e7Jkb3NC    • We enjoyed Nikhil Krishnan of Out-Of-Pocket's take on AI in healthcare, including his thoughts on defensibility and AI's impact on costs: https://lnkd.in/eVtH4ShC --- Want to stay in the loop? Sign up for the Elion Briefing to get all of the latest healthcare tech news delivered to your inbox 📬 👉 https://bit.ly/49z6AUW

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Should be an interesting conversation about where we are today on 50% of the healthcare costs, are these costs fair from a sustainability standpoint, does price influence quality or access? We know the price paid does not equal the cost to deliver a service, so do we have the price right? Shouldn’t we move upstream to better support/incent care earlier to prevent and mitigate some of these higher costs in the primary care setting? How do we make that happen?

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I have so much empathy for the employers and patients who are navigating the GLP-1 landscape right now. BCBS Michigan announced last month that they are dropping coverage for their fully insured population after “careful consideration of GLP-1 weight loss drugs' efficacy, safety and access, and cost.” It’s heartbreaking that there is so much uncertainty on how to effectively cover GLP-1s. This topic dominated talks I heard at AHIP last month. Whether a group decides not to cover at all or limit access through PA, time limits, or narrow prescribing networks - sponsors are working hard to figure this out. But the one thing that remains clear is that regardless of what path is chosen, comprehensive lifestyle change must remain front and center. At Omada Health, we’ve seen that higher engagement with our programs alongside GLP-1 use leads to more weight loss than GLP-1s alone. Equipping people with the support they need to succeed long-term on these drugs has to be a bigger part of the conversation. https://buff.ly/3LMB8ZL

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“The Future of Value-Based Care and Outpatient Joint Replacement” By: Nate Holton, MHA, PHD. Value-Based Care (VBC) represents a transformative shift in healthcare from quantity to quality. Rather than compensating providers per procedure, VBC rewards them for achieving better patient outcomes and delivering high value. This approach is particularly relevant in orthopedic joint replacement, where the success of surgery and recovery directly impact healthcare value. In the coming years, VBC will likely align more closely with outpatient surgery centers for joint replacements. These centers offer a cost-effective environment where quality standards can still be met. With fewer overhead expenses than hospitals, outpatient centers reduce overall costs for joint replacement surgeries, which aligns with VBC’s emphasis on efficiency and high-quality care. Advances in surgical techniques and pain management now make it possible for patients to recover safely at home, making outpatient centers a viable alternative to traditional inpatient care. To support this shift, orthopedic device companies will need to innovate with solutions that meet the needs of outpatient settings. However, it’s not just about speed or quick recovery—innovation must focus on accurate, cost-effective technologies that provide the best outcomes without losing sight of reimbursement structures and bundled care processes. This means delivering precise information and products that enhance the entire care pathway, ensuring every step contributes meaningfully to patient health and cost sustainability. Sources: Health Affairs, CMS.gov, American Association of Hip and Knee Surgeons. Journal of Orthopaedic Research New England Journal of Medicine What are your thoughts, LinkedIn? Do you agree or disagree with these anticipated changes? #healthcare #devicenation #meddevvice #medicaldevice #orthosales #valuebasedcare #vbc #outpatientjointd

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Activation and engagement are critical pieces to a #primarycare model that seeks to manage a population proactively.

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Walmart closing 51 Health Centers over “Lack of Profitability!” Walmart Health Virtual Care (telemedicine) offerings will also end. Article by Daniella Alessandra Genovese Fox Business Network April 30, 2024 MY TAKE: · What does ‘lack of Profitability” really MEAN? o Is it meant that this service line is losing money – financially upside down? o Or does it mean that the line is not producing the “EXCESS PROFITS” that were envisioned - and that corporate leaders and shareholders demand?   ·    Healthcare delivery is NOT a simple business model, though increasingly we see corporate entities entering this arena, often envisioning large profits or - in the case of private equity - valuable ASSETS whose value can be accelerated over short periods - or at least sold off as value-added components.   ·    It has been said that the LURE of ‘excess profit’ invariably leads to GREED, and that in healthcare - greed invariable leads to worsening conditions within healthcare workplaces and worsening outcomes for patients! American Medical Association American Hospital Association American College of Emergency Physicians U.S. Senate Committee on Health, Education, Labor, & Pensions Tennessee Medical Association Jesse Pines Chadd Kraus Lara Vanyo Rita Manfredi TENNESSEE COLLEGE OF EMERGENCY PHYSICIANS Timothy Wilson Ryan Stanton Gabe Kelen, Deidre McPhillips Mollie Pillman Alison Haddock, MD, FACEP Susan Morse mor Chelsea Torres Amy Feldman Jesse Ehrenfeld MD MPH Mel Cortez Larry Bucshon, M.D. Peter Stavros Fox article link - https://lnkd.in/gynsbScT

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The recently announced 2025 Medicare STAR ratings *shook* the public markets and *may* have even prompted major leadership changes in the managed care industry. Every day, a new plan appears to be suing the Centers for Medicare & Medicaid Services in federal court. And annual enrollment where STAR ratings (presumably) should shape sales and marketing behavior is in full swing. So what’s all the fuss about? On the surface, it’s about plan quality. But it is *so* much more. Including how much plans get paid. In my latest Forbes blog, “Trick or Treat: Medicare Advantage STAR Ratings,” I delve deep into why STAR ratings matter and how plans navigate an increasingly complex terrain. I demystify: -how plan payment varies by STAR ratings -how STAR ratings influence a plan’s ability to sell -how plans exploit loopholes to manipulate their STAR ratings -the origins of the legal strategy being employed to challenge 2024-2025 STAR ratings Take a read! https://lnkd.in/gRPyCQvE

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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.

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Interested in the CMS Medicare Shared Savings Program (MSSP), but not sure where to start? Check out this Sg2 expert blog post on how MSSP provides a structure for intentional strategic exploration and learnings, even for systems not fully committed to value-based care.

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Shifting the financial model alone is not sufficient for the transition - the care delivery, workforce, and many other pieces of the ecosystem with which PCPs interact also need to adjust accordingly. Funding to allow for the startup costs of transformation must be made available. A comprehensive analysis from The Commonwealth Fund: To encourage participation, practitioners say upfront payments, investment in the primary care workforce, and less emphasis on simplistic quality measures are needed, as well as more support for practices to provide accessible, comprehensive care. #primarycare #integratedcare #teambasedcare #healthcare #healthcareonlinkedin

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Why do UnitedHealth's #MedicareAdvantage patients have a 15x higher rate of diabetic cataract diagnoses versus the general population? Hint: the vast majority of them don't actually have diabetes. Some don't even have cataracts. But each one of these diagnoses adds $2863 to the insurer's bottom line each year. This WSJ article uncovered a similar story for HIV, AFib, and Parkinson's, across many MA plans (not just from United). CMS administrators won't admit this in public, but Medicare Advantage's risk adjustment formula is basically a license to steal. CMS shouldn't be paying for things that it can't effectively police. #ethicalhealthcare #hippocraticcapitalism #healthcarefraud

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Many people have a limited view of value-based care and the scope of its goals. In reality, the true purpose of VBC is to prioritize patient outcomes, health equity, and cost efficiency over the sheer volume of services provided—it's all about quality! VBC is reshaping the health care landscape, and with proper adoption, can promote greater collaboration among health professionals and improve access to quality care for underserved populations. #ValueBasedCare #VBC #Healthcare https://lnkd.in/gax8xWpB

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More proof that complex drug pricing rules are just playgrounds for big, rich hospital corporations. This might seem esoteric, but whether you're a patient or a doctor, it impacts YOU. The 340B program was designed to help hospitals serving many low-income patients by forcing drug companies to sell outpatient drugs at a steep discount. Picture the government mandating that drink suppliers give massive discounts to restaurants, which then sell these drinks at full price and pocket the difference. A nudge for those serving the needy. But oh, how noble causes can twist and turn... Thanks to both legislative and administrative expansions, hospitals now can hawk these cut-rate drugs through an endless number of off-site pharmacies. Plus, if a hospital snaps up a clinic, that clinic gets the discount gravy train, too. Imagine if a restaurant could offload its budget beverages through countless food trucks, stands, and vending machines—all while raking in the full-price profits. And there’s more. Hospitals can sell these discounted drugs to any patient, covered by any insurance, including private plans or Medicare, without any oversight on how they use the profits. So, a restaurant buys cheap drinks citing a few poor patrons but sells them at premium prices to the wealthy, then uses the profits to gobble up more eateries and pay hefty executive salaries. You can see how the empire builds from there. At one point, CMS wanted to control this spree, at least for Medicare, by paying less for 340B drugs. But the Supreme Court killed that move. Now CMS owes those hospitals for their "losses." As Sayeh Nikpay sharply points out, the fattest checks will line the pockets of the wealthiest corporations, while the hospitals originally meant to benefit get the short end of the stick. Deborah Williams Adam Fein Larry Bucshon, M.D. Joanne Spetz Tom Romeo, MPH https://lnkd.in/gGdqEQew

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"Prescription Drug and Inflationary Pressures Drive 2025 Health Insurance Premium Increases"💊📊📤 Soaring prescription drug costs and the broader economic climate of inflation are the primary factors contributing to anticipated health insurance premium hikes in 2025. The escalating price of prescription medications, particularly specialty drugs used to treat complex diseases, is a significant driver of healthcare expenditures. Additionally, the increased utilization of GLP-1 medications for diabetes and obesity management has exacerbated overall drug costs. Concurrent with this trend, inflationary pressures across the healthcare industry, encompassing medical supplies, labor, and operational expenses, are further contributing to premium increases. The combined effect of these factors will result in higher premiums for both individuals and employers. This financial burden may necessitate adjustments to benefit packages and employee compensation strategies. To address these challenges and promote a sustainable healthcare system, a multifaceted approach is required. This includes implementing drug pricing reforms, enacting comprehensive economic policies to mitigate inflation, and optimizing healthcare delivery through technological advancements and administrative efficiencies. **Would you like to delve deeper into a specific aspect of prescription drug costs, inflation, or potential solutions?** https://lnkd.in/ej3Js8MJ

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This should be a major RED FLAG 🚩 for all providers! However, it also creates a significant leverage point for providers who know how to use it at the negotiating table. Payers need broad networks to maintain MA market share and profits. Providers can use that to their advantage at the bargaining table…payers need you more than you need them when it comes to MA. Remember, seniors don’t change doctors, and if forced to decide between keeping an insurer or their provider, 99.9% will change insurers….ask any broker! Learn how to leverage MA with Payers to increase reimbursements. 👉 https://lnkd.in/gRB3rMw3 #EllsworthConsulting #HealthcareInnovation #ConsultingServices #HealthcareLeadership #PayerNegotiations #HealthcareConsulting

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