Rachael Jones, MPA

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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Drex DeFord Advises Simplifying Healthcare for Vendor Risk Reduction: https://lnkd.in/dDvhYsDF First Health Strategic Advisory Board Member & Healthcare Strategist Drex DeFord dives into pressing concerns around the increasingly complex, difficult to manage, and frequently targeted healthcare environment. Drex’s conversations with This Week Health fuel meaningful conversations to spur the change necessary for improving health sector resilience. We’re proud to have such a dedicated member of the healthcare cybersecurity space advising our leaders and ensuring First Health is at the forefront of digital health security innovation. For more insight into First Health’s leadership and board members, visit https://lnkd.in/gQUx5BzD or contact First Health at info@firsthealthadvisory.com. #CISO #CIO #CTO #CDO #Compliance #HIPAA #HealthcareIT #HealthcareSecurity #CyberRisk #ThirdPartyRisk #RiskAssessment #Cybersecurity #HTM #DigitalHealth #PatientSafety

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🔎 Senators See Possible Conflicts of Interest in Health Care Pricing Tools The chairmen of two Senate committees overseeing health policy, Ron Wyden of Oregon and Bernie Sanders of Vermont, are looking into the practices of data analytics firm MultiPlan. Concerned about companies prioritizing their own profits over patient well-being, the senators are investigating MultiPlan's business model, which recommends lower payments to medical providers. This model could lead to a conflict of interest, as MultiPlan and insurers can collect higher fees when payouts are lower. The senators have called on MultiPlan to discuss their investigation and address concerns raised by a recent New York Times article. Read the full article here: Senators See Possible Conflicts of Interest in Health Care Pricing Tools MultiPlan has stated that they are working with the Senate committees to explain the complexities patients face when choosing high-priced care outside their networks, emphasizing their commitment to making healthcare transparent, fair, and affordable for all. This inquiry reflects the growing scrutiny of MultiPlan, which has faced allegations of anticompetitive behavior and collusion with insurers to fix prices. The Department of Labor also has ongoing investigations into the type of pricing services provided by MultiPlan. The attention on MultiPlan highlights the importance of employer-based health insurance, which is the most common way Americans receive coverage. Employers are increasingly looking into the cost of administering their plans and are frustrated by limited access to claims data. Legislation has been introduced to address this issue, requiring insurers to provide employers with claims data. As the investigation unfolds, it remains to be seen how MultiPlan and insurers will address concerns and ensure that patient well-being is prioritized over profits. #HealthCarePricing #PatientAdvocacy #HealthInsurance #DataAnalytics #SenateCommittees

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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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New Online Course! CMS-HCC Risk Adjustment Model Version 28: Be Proactive What can you do to mitigate the impact of the Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Codes (CMS-HCC) risk adjustment model Version 28? This online course reveals a proactive approach to mitigating the potential negative impact of Version 28 through proper identification of diseases and conditions coupled with addressing, assessing, and properly treating those diseases. It follows clinical and coding guidelines to address diagnoses and conditions for which the risk adjustment factor has been eliminated or reduced. It does this through a disciplined approach of reviewing co-morbid conditions, alternative diagnoses, and improved specificity. In all cases, the primary purpose is to treat the patient's diagnoses and conditions to improve the quality of life for the patient. Learn more about this course at https://lnkd.in/eVmECiEs. #CMS #hcquality #patientcare

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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 highest increase since 2012 highlights the pressing need for further action to curb increases in medical cost trend. Insurers should prepare for tougher contract negotiations as providers strive to enhance their financial standing and offset stagnant Medicare and Medicaid reimbursement rates.

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The Basics of Risk Adjustment Here’s what stood out to me: In capitated payment models, accurately predicting patients’ future healthcare costs is critical. Risk adjustment helps ensure that providers are paid enough to deliver appropriate care to all their patients, regardless of their individual care needs. However, if done poorly, it could exacerbate health inequities by misallocating resources. Check out the full piece below: https://buff.ly/3yPjVfn #healthcare #hospitals #doctors #riskadjustment #individualcare

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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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AccendoWave - A Pain #Data Company More recently, the federal government has begun using the QIS program and QRS parameters to advance health equity. Federal rules now require all marketplace insurers to adopt a strategy for reducing health disparities and to stratify certain clinical data by race and ethnicity. While state-based marketplaces (SBMs) have authority to supplement these federal minimum QIS and QRS standards with state-specific quality rules, most have hewed closely to the federal default approach. California and Washington are notable exceptions. Each has implemented a customized QIS program and robust data collection standards to identify and reduce racial and ethnic health disparities. Time to Focus on - #Pain not being Believed. A Root Cause Health Equity Problem. A Top 4 Global Health Equity Solution and Top 15 Global Remote Monitoring Company, AccendoWave, benchmarks objective brain wave pain data (specialty, gender, age) and has nine #pain databases: Emergency Department, Maternal Health, Oncology, MSK, Medical Surgical, ICU, #Women, Adults, #Seniors to eliminate bias, improve outcomes and reduce health care costs. If desired, AccendoWave can also create customized pain databases for partners that can be accessed on the Datavant platform.

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💡 In Onpoint’s new issue brief, our Director of Data Analytics Jesse Drummond, PhD, and Director of Health Analytics Amy Kinner, MS, discuss a new method for addressing the challenge of attributing #healthcare providers to practices using claims data from all-payer claims databases (APCDs). Many #APCDs are working hard to report on performance at the practice level – rather than at the provider level – and creating practice rosters is a crucial step in this process. While Onpoint has been attributing patients to their primary care providers using claims data for many years, accurately attributing providers to practices requires both experience and #innovation. Want to learn about our team’s new method for overcoming these challenges? Follow the link below! 👇 https://lnkd.in/eZajB32W

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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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https://lnkd.in/gMUpgFgC Check out Beterra's latest blog, and check back for more Beterra thoughts on the CMS Proposed Patient Safety Structural Measure (PSSM). #healthcare, #safety, #cms, #pssm

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Healthcare has made improvements but there's still a long way to go to become truly digital-first. While we've seen advancements in telemedicine, electronic health records, and AI-driven diagnostics, the journey to fully integrate these technologies into everyday practice is far from complete. And the “door” to care – patient navigation – needs a lot of work. If we don't evolve, patient's will find others who do! https://lnkd.in/eSJKiHSR #patientcentricity #digitalfirst #digitaltransformation #patientnavigation

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Great commentary and details to be considered from post by Deborah Williams Too few probably understand what you've posted, the other major part of the problem. Commercial insured populations (employers & employees) pay the price for government policy failures that represent major hits on company bottom lines or lead to more individual bankruptcies today. #employeebenefits #employers #commerialinsurance #epcouncil.org

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If health systems master the art of delivering a world-class consumer experience in urgent care, they can replicate this success across their entire operation, becoming market leaders and thriving in the long term. This is the core thesis of what we do at UCP Merchant Medicine. For nine years, UCP Merchant Medicine has partnered with 68 healthcare operators, most of whom are health systems, to create internal capabilities that allow them to thrive in consumer experience excellence. This isn’t just about having a world-class urgent care platform, this is about owning the future and the capabilities to expand these experiences across the broader health system. As healthcare shifts towards a consumer-driven model, the need for health systems to adapt is more critical than ever. Patients now have unprecedented freedom to choose their care providers, with 45% researching providers and costs before choosing a health plan, and 44% before making an appointment, according to McKinsey’s consumer Health Insights Survey. These improvements are not just numbers; they're about real people getting better access to the care they need when they need it in a way that they will love. This is what we stand for at UCP Merchant Medicine. Join us as we continue to innovate and lead the way in making healthcare more responsive, efficient, and patient-centric. Together, we can transform the future of healthcare! #HealthcareInnovation #PatientCare #UrgentCare #HealthcareLeadership #UCPMerchantMedicine Intellivisit Solutions

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Insurance companies with the resources, money to deploy AI in healthcare is making patient care more difficult. Too big to care and "too big to fail" Time for allyship and an alliance to meet the challenges of AI before it's too late? "Humana used AI tool from UnitedHealth to deny Medicare Advantage claims, lawsuit alleges" "Humana used an artificial intelligence tool owned by UnitedHealth Group to wrongfully deny Medicare Advantage members' medical claims, according to a class-action complaint filed Dec. 12." #AI #ArtificialIntelligence #TooBigtoCare #TooBigtoFail #Patients #HealthcareAdvocacy #Healthcare #HealthcareHeroes #HealthcareProfessionals #Nurses #Doctors #NursesOnLinkedin #Nursing #HealthcareOnLinkedin #AMA #ANA #AIHealthcare #Copyright  #Credentialed #Licensed #Regulated #Regulation #EnoughIsEnough #WhatWillItTake #SeatattheTable #StrongerTogether #BetterTogether https://lnkd.in/gNJ8SjvR

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Interoperability standards continue to shape the #healthcare industry from #CMS regulations to #HEDIS reporting. To set themselves up for continued success, payers must anticipate the coming shifts, and stay ahead of the ever-evolving landscape. 💭 A recent byline in DOTmed.com, Inc from our client Cotiviti dives into the necessary steps payers must take to ensure these standards are met for seamless #dataexchange: https://lnkd.in/ghGB_txj #interoperability #datasharing #FHIR 

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