The Terry Group’s Post

🚨 Big News in Healthcare Payment Reform! 🚨 Senators Sheldon Whitehouse (D-RI) and Dr. Bill Cassidy (R-LA) have introduced the Pay PCPs Act to revamp how primary care providers are compensated under Medicare. This legislation aims to address the primary care physician shortage, enhance patient outcomes, and reduce healthcare costs. Key points include: - Hybrid payment models rewarding quality care. - Reduced cost-sharing for Medicare beneficiaries. - Establishing a technical advisory committee for accurate fee schedules. Let's drive the change towards a healthier future! 🌟

Understanding MA plans’ regulatory obligations and your enforcement options is critical. We help negotiate contract terms that align with plans’ commitments to CMS giving providers a direct and clear means to enforce payment rules.

As we look ahead to a new administration, the Centers for Medicare & Medicaid Services (CMS) has outlined its vision for continuing to strengthen the Medicare program, particularly regarding access to essential treatments and services. In a piece for Health Affairs, Meena Seshamani, Chiquita Brooks-LaSure, and Rachel Weiss write: "Access to vital care also forms the basis for the next round of beneficiary-focused proposals in the current Medicare Advantage and Part D rule, such as expanding access to Anti-Obesity Medications..." Read more in Health Affairs: https://lnkd.in/eBZHBHSk       

It continues to be encouraging to see the commitment that the Centers for Medicare & Medicaid Services has toward expanding and enriching pathways for more #Medicare patients to receive care in an accountable relationship. This Health Affairs Forefront article authored by CMMI and CMS leadership summarizes those efforts and highlights the proposed change in the 2025 Physician Fee Schedule introducing Advanced Primary Care Management billing codes to help support primary care practices that are delivering more robust care management and advanced primary care services to Medicare patients. As with RPM and CCM codes I expect that a small subset of practices will engage in these billing codes initially, but for those who are well setup to do so it provides a more sustainable funding mechanism to bring more dollars into Primary Care and help to create a hybrid financial model between FFS and Full Capitation. I’m curious what others think about these proposed codes https://lnkd.in/eurGqvPW

Providers Are Fed Up With Medicare Advantage More and more health systems are parting ways with big-name Medicare Advantage plans for good reason. Hassles, denying care for inpatient level of care, denying authorization for outpatient scheduled procedures, putting up roadblocks for payment according to the negotiated contract terms, requesting more medical records prepayment to slow down payment, hiring contractors to steal back monies for paid claims one to two years earlier, second-guessing physicians clinical judgment and medical decision making in diagnosing through clinical validation denials, etc. This sums it up well: "Moreover, this trend could lead to even more scrutiny and potential reforms in Medicare Advantage policies. Stakeholders, including policymakers, may need to address the concerns raised by providers to ensure that MA plans can fulfill their promise of comprehensive, accessible care without imposing undue burdens on healthcare systems." I suggest : Moreover, this trend must lead to even more scrutiny and potential reforms in Medicare Advantage policies. Stakeholders, including policymakers, must address the concerns raised by providers to ensure that MA plans can fulfill their promise of comprehensive, accessible care without imposing undue burdens on healthcare systems. Medicare Advantage is leading the innovative use of value-based care — delivering better health outcomes, through better quality care at a better cost for Medicare beneficiaries according to the trade group for Medicare Advantage plans- Better Medicare Alliance. Mission of this organization- More than 33 million beneficiaries have made the choice to enroll in Medicare Advantage. Seniors and people with disabilities deserve quality health care — and we believe Medicare Advantage provides the opportunity for a healthier future. Medicare Advantage Plans provide for a healthier future for their C suites and shareholders through healthy profits and stock dividends paid on the backs of providers and beneficiaries who are denied needed care such as SNF and rehab, services Humana has a tendency to deny or if you are UHC, use AI to determine when to stop paying for inpatient rehab/SNF. #MedicareAdvantage, #Medicaredisadvantage, #profitfirst, #reininginMAplans https://lnkd.in/exujjGN6

Health Affairs provides the authors (Centers for Medicare & Medicaid Services leaders) an opportunity to summarize their portfolio approach to achieving the stated goal - having 100% of Medicare beneficiaries in an accountable provider relationship by 2030. This is a helpful for those of you looking at the #valuebasedcare national landscape over the next three to five years, especially if you are supporting or selling into providers and provider organizations.

A new report from MedPage Today reveals a significant increase in prior authorizations within Medicare Advantage plans, closely mirroring the rise in Medicare Advantage enrollment. As more seniors opt for these plans, healthcare providers are feeling the unfortunate impact of added administrative hurdles. Prior authorizations play a critical role in ensuring that patients receive appropriate and cost-effective care. With healthcare constantly changing, it's important for providers and patients alike to stay informed about these trends and develop strategies to streamline the prior authorization process. #healthcare #medicareadvantage #priorauthorization

🌟 Medicare Advantage Users Demand Broader Care Access! 🌟 A recent study reveals that a staggering 69% of Medicare Advantage enrollees are seeking out-of-network healthcare services! This trend highlights a critical need for flexibility in healthcare access, especially among those with higher health risks. Key Findings: - 43% visit primary care outside their network. - Over 20% consult specialists and nurse practitioners beyond their plan's offerings. - The discontinuation of Cost plans in 2019 led to a notable shift, with higher-risk individuals transitioning to traditional Medicare. This underscores the importance of comprehensive network access in enhancing satisfaction and retention among enrollees. Policymakers and plan administrators must take note: accommodating the diverse needs of Medicare beneficiaries is essential for better health outcomes! 🏥💪 👉 Click the link to delve deeper into these findings! #HealthEconomics #HealthOutcomes #HealthcareAccess #MedicareAdvantage #PolicyChange #Publications #RegulatoryAgencies #MarketAccess #MarketAccessToday

A significant portion of healthcare spending is allocated to patients in their last year of life. Specifically, studies indicate that approximately 25% of Medicare expenditures are spent on beneficiaries during their final year. This statistic highlights the substantial financial resources directed towards end-of-life care, reflecting the intensity of medical services utilized during this period. Moreover, it has been noted that 62% of individuals in the top 5% of healthcare spenders are often those who are nearing the end of life, further emphasizing the concentration of healthcare costs in this demographic. This trend is consistent across various healthcare systems, where end-of-life care tends to consume a disproportionate share of overall health budgets.

Changes could be coming to Medicare! The latest proposed CMS rule changes aim to enhance affordability and equity in healthcare. Our own Brian Norris MBA, RN, FHIMSS breaks down how these updates will impact healthcare organizations and what you need to know. #Medicare #HealthcareReform #MedeAnalytics