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Dr. Nathan Pennell and Dr. Cheryl Czerlanis discuss challenges in lung cancer screening and potential solutions to increase screening rates, including the use of AI to enhance risk prediction and screening processes. Transcript Dr. Nate Pennell: Hello, and welcome to By the Book, a monthly podcast series for ASCO Education that features engaging discussions between editors and authors from the ASCO Educational Book. I'm Dr. Nate Pennell, the co-director of the Cleveland Clinic Lung Cancer Program and vice chair of clinical research for the Taussig Cancer Center. I'm also the editor-in-chief for the ASCO Educational Book.  Lung cancer is one of the leading causes of cancer-related mortality worldwide, and most cases are diagnosed at advanced stages where curative treatment options are limited. On the opposite end, early-stage lung cancers are very curable. If only we could find more patients at that early stage, an approach that has revolutionized survival for other cancer types such as colorectal and breast cancer.  On today's episode, I'm delighted to be joined by Dr. Cheryl Czerlanis, a professor of medicine and thoracic medical oncologist at the University of Wisconsin Carbone Cancer Center, to discuss her article titled, "Broadening the Net: Overcoming Challenges and Embracing Novel Technologies in Lung Cancer Screening." The article was recently published in the ASCO Educational Book and featured in an Education Session at the 2025 ASCO Annual Meeting. Our full disclosures are available in the transcript of this episode.  Cheryl, it's great to have you on the podcast today. Thanks for being here. Dr. Cheryl Czerlanis: Thanks, Nate. It's great to be here with you. Dr. Nate Pennell: So, I'd like to just start by asking you a little bit about the importance of lung cancer screening and what evidence is there that lung cancer screening is beneficial. Dr. Cheryl Czerlanis: Thank you. Lung cancer screening is extremely important because we know that lung cancer survival is closely tied to stage at diagnosis. We have made significant progress in the treatment of lung cancer, especially over the past decade, with the introduction of immunotherapies and targeted therapies based on personalized evaluation of genomic alterations. But the reality is that outside of a lung screening program, most patients with lung cancer present with symptoms related to advanced cancer, where our ability to cure the disease is more limited.  While lung cancer screening has been studied for years, the National Lung Screening Trial, or the NLST, first reported in 2011 a significant reduction in lung cancer deaths through screening. Annual low-dose CT scans were performed in a high-risk population for lung cancer in comparison to chest X-ray. The study population was comprised of asymptomatic persons aged 55 to 74 with a 30-pack-year history of smoking who were either active smokers or had quit within 15 years. The low-dose CT screening was associated with a 20% relative risk reduction in lung cancer-related mortality. A similar magnitude of benefit was also reported in the NELSON trial, which was a large European randomized trial comparing low-dose CT with a control group receiving no screening. Dr. Nate Pennell: So, this led, of course, to approval from CMS (Centers for Medicare and Medicaid Services) for lung cancer screening in the Medicare population, probably about 10 years ago now, I think. And there are now two major trials showing an unequivocal reduction in lung cancer-related mortality and even evidence that it reduces overall mortality with lung cancer screening. But despite this, lung cancer screening rates are very low in the United States. So, first of all, what's going on? Why are we not seeing the kinds of screening rates that we see with mammography and colonoscopy? And what are the barriers to that here? Dr. Cheryl Czerlanis: That's a great question. Thank you, Nate. In the United States, recruitment for lung cancer screening programs has faced numerous challenges, including those related to socioeconomic, cultural, logistical, and even racial disparities. Our current lung cancer screening guidelines are somewhat imprecise and often fail to address differences that we know exist in sex, smoking history, socioeconomic status, and ethnicity. We also see underrepresentation in certain groups, including African Americans and other minorities, and special populations, including individuals with HIV. And even where lung cancer screening is readily available and we have evidence of its efficacy, uptake can be low due to both provider and patient factors. On the provider side, barriers include having insufficient time in a clinic visit for shared decision-making, fear of missed test results, lack of awareness about current guidelines, concerns about cost, potential harms, and evaluating both true and false-positive test results.  And then on the patient side, barriers include concerns about cost, fear of getting a cancer diagnosis, stigma associated with tobacco smoking, and misconceptions about the treatability of lung cancer. Dr. Nate Pennell: I think those last two are really what make lung cancer unique compared to, say, for example, breast cancer, where there really is a public acceptance of the value of mammography and that breast cancer is no one's fault and that it really is embraced as an active way you can take care of yourself by getting your breast cancer screening. Whereas in lung cancer, between the stigma of smoking and the concern that, you know, it's a death sentence, I think we really have some work to be made up, which we'll talk about in a minute about what we can do to help improve this.  Now, that's in the U.S. I think things are probably, I would imagine, even worse when we leave the U.S. and look outside, especially at low- and middle-income countries. Dr. Cheryl Czerlanis: Yes, globally, this issue is even more complex than it is in the United States. Widespread implementation of low-dose CT imaging for lung cancer screening is limited by manpower, infrastructure, and economic constraints. Many low- and middle-income countries even lack sufficient CT machines, trained personnel, and specialized facilities for accurate and timely screenings. Even in urban centers with advanced diagnostic facilities, the high screening and follow-up care costs can limit access. Rural populations face additional barriers, such as geographic inaccessibility of urban centers, transportation costs, language barriers, and mistrust of healthcare systems. In addition, healthcare systems in these regions often prioritize infectious diseases and maternal health, leaving limited room for investments in noncommunicable disease prevention like lung cancer screening. Policymakers often struggle to justify allocating resources to lung cancer screening when immediate healthcare needs remain unmet. Urban-rural disparities exacerbate these challenges, with rural regions frequently lacking the infrastructure and resources to sustain screening programs. Dr. Nate Pennell: Well, it's certainly an intimidating problem to try to reduce these disparities, especially between the U.S. and low- and middle-income countries. So, what are some of the potential solutions, both here in the U.S. and internationally, that we can do to try to increase the rates of lung cancer screening? Dr. Cheryl Czerlanis: The good news is that we can take steps to address these challenges, but a multifaceted approach is needed. Public awareness campaigns focused on the benefits of early detection and dispelling myths about lung cancer screening are essential to improving participation rates. Using risk-prediction models to identify high-risk individuals can increase the efficiency of lung cancer screening programs. Automated follow-up reminders and screening navigators can also ensure timely referrals and reduce delays in diagnosis and treatment. Reducing or subsidizing the cost of low-dose CT scans, especially in low- or middle-income countries, can improve accessibility. Deploying mobile CT scanners can expand access to rural and underserved areas.  On a global scale, integrating lung cancer screening with existing healthcare programs, such as TB or noncommunicable disease initiatives, can enhance resource utilization and program scalability. Implementing lung cancer screening in resource-limited settings requires strategic investment, capacity building, and policy interventions that prioritize equity. Addressing financial constraints, infrastructure gaps, and sociocultural barriers can help overcome existing challenges. By focusing on cost-effective strategies, public awareness, and risk-based eligibility criteria, global efforts can promote equitable access to lung cancer screening and improve outcomes.  Lastly, as part of the medical community, we play an important role in a patient's decision to pursue lung cancer screening. Being up to date with current lung cancer screening recommendations, identifying eligible patients, and encouraging a patient to undergo screening often is the difference-maker. Electronic medical record (EMR) systems and reminders are helpful in this regard, but relationship building and a recommendation from a trusted provider are really essential here. Dr. Nate Pennell: I think that makes a lot of sense. I mean, there are technology improvements. For example, our lung cancer screening program at The Cleveland Clinic, a few years back, we finally started an automated best practice alert in our EMR for patients who met the age and smoking requirements, and it led to a six-fold increase in people referred for screening. But at the same time, there's a difference between just getting this alert and putting in an order for lung cancer screening and actually getting those patients to go and actually do the screening and then follow up on it. And that, of course, requires having that relationship and discussion with the patient so that they trust that you have their best interests. Dr. Cheryl Czerlanis: Exactly. I think that's important. You know, certainly, while technology can aid in bringing patients in, there really is no substitute for trust-building and a personal relationship with a provider. Dr. Nate Pennell: I know that there are probably multiple examples within the U.S. where health systems or programs have put together, I would say, quality improvement projects to try to increase lung cancer screening and working with their community. There's one in particular that you discuss in your paper called the "End Lung Cancer Now" initiative. I wonder if you could take us through that. Dr. Cheryl Czerlanis: Absolutely. "End Lung Cancer Now" is an initiative at the Indiana University Simon Comprehensive Cancer Center that has the vision to end suffering and death from lung cancer in Indiana through education and community empowerment. We discuss this as a paradigm for how community engagement is important in building and scaling a lung cancer screening program.  In 2023, the "End Lung Cancer Now" team decided to focus its efforts on scaling and transforming lung cancer screening rates in Indiana. They developed a task force with 26 experts in various fields, including radiology, pulmonary medicine, thoracic surgery, public health, and advocacy groups. The result of this work is an 85-page blueprint with key recommendations that any system and community can use to scale lung cancer screening efforts. After building strong infrastructure for lung cancer screening at Indiana University, they sought to understand what the priorities, resources, and challenges in their communities were. To do this, they forged strong partnerships with both local and national organizations, including the American Lung Association, American Cancer Society, and others. In the first year, they actually tripled the number of screening low-dose CTs performed in their academic center and saw a 40% increase system-wide. One thing that I think is the most striking is that through their community outreach, they learned that most people prefer to get medical care close to home within their own communities. Establishing a way to support the local infrastructure to provide care became far more important than recruiting patients to their larger system.  In exciting news, "End Lung Cancer Now" has partnered with the IU Simon Comprehensive Cancer Center and IU Health to launch Indiana's first and only mobile lung screening program in March of 2025. This mobile program travels around the state to counties where the highest incidence of lung cancer exists and there is limited access to screening. The mobile unit parks at trusted sites within communities and works in partnership, not competition, with local health clinics and facilities to screen high-risk populations. Dr. Nate Pennell: I think that sounds like a great idea. Screening is such an important thing that it doesn't necessarily have to be owned by any one particular health system for their patients. I think. And I love the idea of bringing the screening to patients where they are. I can speak to working in a regional healthcare system with a main campus in the downtown that patients absolutely hate having to come here from even 30 or 40 minutes away, and they'd much rather get their care locally. So that makes perfect sense.  So, under the current guidelines, there are certainly things that we can do to try to improve capturing the people that meet those. But are those guidelines actually capturing enough patients with lung cancer to make a difference? There certainly are proposals within patient advocacy communities and even other countries where there's a large percentage of non-smokers who perhaps get lung cancer. Can we expand beyond just older, current and heavy smokers to identify at-risk populations who could benefit from screening? Dr. Cheryl Czerlanis: Yes, I think we can, and it's certainly an active area of research interest. We know that tobacco is the leading cause of lung cancer worldwide. However, other risk factors include secondhand smoke, family history, exposure to environmental carcinogens, and pulmonary diseases like COPD and interstitial lung disease. Despite these known associations, the benefit of lung cancer screening is less well elucidated in never-smokers and those at risk of developing lung cancer because of family history or other risk factors. We know that the eligibility criteria associated with our current screening guidelines focus on age and smoking history and may miss more than 50% of lung cancers. Globally, 10% to 25% of lung cancer cases occur in never-smokers. And in certain parts of the world, like you mentioned, Nate, such as East Asia, many lung cancers are diagnosed in never-smokers, especially in women. Risk-prediction models use specific risk factors for lung cancer to enhance individual selection for screening, although they have historically focused on current or former smokers.  We know that individuals with family members affected by lung cancer have an increased risk of developing the disease. To this end, several large-scale, single-arm prospective studies in Asia have evaluated broadening screening criteria to never-smokers, with or without additional risk factors. One such study, the Taiwan Lung Cancer Screening in Never-Smoker Trial, was a multicenter prospective cohort study at 17 medical centers in Taiwan. The primary outcome of the TALENT trial was lung cancer detection rate. Eligible patients aged 55 to 75 had either never smoked or had a light and remote smoking history. In addition, inclusion required one or more of the following risk factors: family history of lung cancer, passive smoke exposure, history of TB or COPD, a high cooking index, which is a metric that quantifies exposure to cooking fumes, or a history of cooking without ventilation. Participants underwent low-dose CT screening at baseline, then annually for 2 years, and then every 2 years for up to 6 years. The lung cancer detection rate was 2.6%, which was higher than that reported in the NLST and NELSON trials, and most were stage 0 or I cancers. Subsequently, this led to the Taiwan Early Detection Program for Lung Cancer, a national screening program that was launched in 2022, targeting 2 screening populations: individuals with a heavy history of smoking and individuals with a family history of lung cancer.  We really need randomized controlled trials to determine the true rates of overdiagnosis or finding cancers that would not lead to morbidity or mortality in persons who are diagnosed, and to establish whether the high lung detection rates are associated with a decrease in lung cancer-related mortality in these populations. However, the implementation of randomized controlled low-dose CT screening trials in never-smokers has been limited by the need for large sample sizes, lengthy follow-up, and cost.  In another group potentially at higher risk for developing lung cancer, the role of lung cancer screening in individuals who harbor germline pathogenic variants associated with lung cancer also needs to be explored further. Dr. Nate Pennell: We had this discussion when the first criteria came out because there have always been risk-based calculators for lung cancer that certainly incorporate smoking but other factors as well and have discussion about whether we should be screening people based on their risk and not just based on discrete criteria such as smoking. But of course, the insurance coverage for screening, you have to fit the actual criteria, which is very constrained by age and smoking history. Do you think in the U.S. there's hope for broadening our screening beyond NLST and NELSON criteria? Dr. Cheryl Czerlanis: I do think at some point there is hope for broadening the criteria beyond smoking history and age, beyond the criteria that we have typically used and that is covered by insurance. I do think it will take some work to perhaps make the prediction models more precise or to really understand who can benefit. We certainly know that there are many patients who develop lung cancer without a history of smoking or without family history, and it would be great if we could diagnose more patients with lung cancer at an earlier stage. I think this will really count on there being some work towards trying to figure out what would be the best population for screening, what risk factors to look for, perhaps using some new technologies that may help us to predict who is at risk for developing lung cancer, and trying to increase the group that we study to try and find these early-stage lung cancers that can be cured. Dr. Nate Pennell: Part of the reason we, of course, try to enrich our population is screening works better when you have a higher pretest probability of actually having cancer. And part of that also is that our technology is not that great. You know, even in high-risk patients who have CT scans that are positive for a screen, we know that the vast majority of those patients with lung nodules actually don't have lung cancer. And so you have to follow them, you have to use various models to see, you know, what the risk, even in the setting of a positive screen, is of having lung cancer.  So, why don't we talk about some newer tools that we might use to help improve lung cancer screening? And one of the things that everyone is super excited about, of course, is artificial intelligence. Are there AI technologies that are helping out in early detection in lung cancer screening? Dr. Cheryl Czerlanis: Yes, that's a great question. We know that predicting who's at risk for lung cancer is challenging for the reasons that we talked about, knowing that there are many risk factors beyond smoking and age that are hard to quantify. Artificial intelligence is a tool that can help refine screening criteria and really expand screening access. Machine learning is a form of AI technology that is adept at recognizing patterns in large datasets and then applying the learning to new datasets. Several machine learning models have been developed for risk stratification and early detection of lung cancer on imaging, both with and without blood-based biomarkers. This type of technology is very promising and can serve as a tool that helps to select individuals for screening by predicting who is likely to develop lung cancer in the future.  A group at Massachusetts General Hospital, represented in our group for this paper by my co-authors, Drs. Fintelmann and Chang, developed Sybil, which is an open-access 3D convolutional neural network that predicts an individual's future risk of lung cancer based on the analysis of a single low-dose CT without the need for human annotation or other clinical inputs. Sybil and other machine learning models have tremendous potential for precision lung cancer screening, even, and perhaps especially, in settings where expert image interpretation is unavailable. They could support risk-adapted screening schedules, such as varying the frequency and interval of low-dose CT scans according to individual risk and potentially expand lung cancer screening eligibility beyond age and smoking history. Their group predicts that AI tools like Sybil will play a major role in decoding the complex landscape of lung cancer risk factors, enabling us to extend life-saving lung cancer screening to all who are at risk. Dr. Nate Pennell: I think that that would certainly be welcome. And as AI is working its way into pretty much every aspect of life, including medical care, I think it's certainly promising that it can improve on our existing technology.  We don't have to spend a lot of time on this because I know it's a little out of scope for what you covered in your paper, but I'm sure our listeners are curious about your thoughts on the use of other types of testing beyond CT screening for detecting lung cancer. I know that there are a number of investigational and even commercially available blood tests, for example, for detection of lung cancer, or even the so-called multi-cancer detection blood tests that are now being offered, although not necessarily being covered by insurance, for multiple types of cancer, but lung cancer being a common cancer is included in that. So, what do you think? Dr. Cheryl Czerlanis: Yes, like you mentioned, there are novel bioassays such as blood-based biomarker testing that evaluate for DNA, RNA, and circulating tumor cells that are both promising and under active investigation for lung cancer and multi-cancer detection. We know that such biomarker assays may be useful in both identifying lung cancers but also in identifying patients with a high-risk result who should undergo lung cancer screening by conventional methods. Dr. Nate Pennell: Anything that will improve on our rate of screening, I think, will be welcome. I think probably in the future, it will be some combination of better risk prediction and better interpretation of screening results, whether those be imaging or some combination of imaging and biomarkers, breath-based, blood-based. There's so much going on that it is pretty exciting, but we're still going to have to overcome the stigma and lack of public support for lung cancer screening if we're going to move the needle. Dr. Cheryl Czerlanis: Yes, I think moving the needle is so important because we know lung cancer is still a very morbid disease, and our ability to cure patients is not where we would like it to be. But I do believe there's hope. There are a lot of motivated individuals and groups who are passionate about lung cancer screening, like myself and my co-authors, and we're just happy to be able to share some ways that we can overcome the challenges and really try and make an impact in the lives of our patients. Dr. Nate Pennell: Well, thank you, Dr. Czerlanis, for joining me on the By the Book Podcast today and for all of your work to advance care for patients with lung cancer. Dr. Cheryl Czerlanis: Thank you, Dr. Pennell. It's such a pleasure to be with you today. Thank you. Dr. Nate Pennell: And thank you to our listeners for joining us today. You'll find a link to Dr. Czerlanis' article in the transcript of this episode.  Please join us again next month for By the Book's next episode and more insightful views on topics you'll be hearing at the education sessions from ASCO meetings throughout the year, and our deep dives on approaches that are shaping modern oncology. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Follow today's speakers:     Dr. Nathan Pennell    @n8pennell   @n8pennell.bsky.social Dr. Cheryl Czerlanis Follow ASCO on social media:     @ASCO on X (formerly Twitter)     ASCO on Bluesky    ASCO on Facebook     ASCO on LinkedIn     Disclosures:    Dr. Nate Pennell:        Consulting or Advisory Role: AstraZeneca, Lilly, Cota Healthcare, Merck, Bristol-Myers Squibb, Genentech, Amgen, G1 Therapeutics, Pfizer, Boehringer Ingelheim, Viosera, Xencor, Mirati Therapeutics, Janssen Oncology, Sanofi/Regeneron       Research Funding (Institution): Genentech, AstraZeneca, Merck, Loxo, Altor BioScience, Spectrum Pharmaceuticals, Bristol-Myers Squibb, Jounce Therapeutics, Mirati Therapeutics, Heat Biologics, WindMIL, Sanofi    Dr. Cheryl Czerlanis: Research Funding (Institution): LungLife AI, AstraZeneca, Summit Therapeutics

Send us a textPhysician space sharing could be a great strategy - if you follow the rules. In this episode, Captain Integrity Bob Wade discusses physician space sharing as it relates to Stark Law compliance with Mike Vetter, Partner at HMS Valuation Partners. Hear why utilizing space sharing arrangements is a very cost-effective strategy for a healthcare system to expand services to other communities, why it starts with communication, why these arrangements are watched by the CMS (Centers for Medicare & Medicaid Services) and the regulatory language set forth, the biggest pitfalls of these types of arrangement, and the hotel room example. Learn more at CaptainIntegrity.com

A referral by a physician of a Designated Health Service (DHS) is the key to opening up the Stark Law City. In this episode, Captain Integrity Bob Wade explains what a DHS is and how they're categorized. Hear why you should add the CMS (Centers for Medicare & Medicaid Services) website page about the Stark Law to your Favorites, which Stark Law categories are defined by the CPT/HCPCS code, the scenarios where the Stark Law doesn't apply, what defines a DHS, and the time Captain Integrity got the Key to the City. Learn more at CaptainIntegrity.com and email Bob to get the slide

For a full transcript of this episode, click here. In this healthcare podcast we're talking about pharmacy acronyms or terms like AWP and WAC, and, not really an acronym, but we'll also talk pharmacy list prices, rebates, discounts. We also have NADAC, but that's slightly off to the side for reasons we'll get to in a sec. Most of these acronyms refer to a number with a dollar sign in front of it, and it's hell on wheels to figure out if and/or to what extent that number reflects what is going on in the real world, especially if you are a patient or a plan sponsor and all you see is the list price that Pharma puts out on one side of the storyboard, and then what the patient pays or (if you're lucky) what the plan pays for the drug on the way other side of the whole chain of events. What's a black box a lot of times for patients and plan sponsors is what goes on in the middle, wherein many middle people get their mitts on the transaction. Real quick here, let's run through the Mister Rogers' neighborhood of all of these middle people right now; and we're gonna do this really briefly. Most of you are already going to know most of this, but I just want to remind you so that when my guest today, Luke Slindee, and I kick into the conversation about the acronyms and the terms and we try to follow the dollar … yeah, you can put a name to a face. Alright, so first we have pharma manufacturers. The pharma manufacturer—and this is largely gonna be true whether it's a branded drug or a generic pharma manufacturer—but the manufacturer sets a list price. This list price is gonna be called an AWP or a WAC price, and we're gonna get into the differences and what those terms actually mean in the show that follows. But Pharma decides their price point. They go to wholesalers with that price. Wholesalers say they want a discount to purchase the product. Some kind of rebate or discount is negotiated. Now the wholesalers have the drug, and they get calls from pharmacies. Pharmacies have patients who have scripts for that, so the pharmacies need to buy the drug. What price does the pharmacy now pay the wholesaler for the drug? Short answer: It's nuts. It's nuts how the wholesalers decide what to charge the pharmacies for the drug. We talk about that in the interview that follows, but suffice to say that now we have the list price turning into whatever price the pharmacies wound up paying to get the drug from the wholesalers for. Any way you cut it, the wholesalers are making some money. Okay … now we get to the part where we're figuring out how much the patient or the plan sponsor will pay to pick up that drug that started at the pharma manufacturers and went to the wholesalers and now is at the pharmacy. How much are the patients gonna pay? How much are the plan sponsors gonna pay? If you spend any time in the real world (not the drug supply chain world), what you'd expect to happen next is that the patient would go into the pharmacy and the pharmacist would charge a markup and/or a dispensing fee on the price that they bought the drug from the wholesaler for. That'd be normal. And this can be the case when patients pay cash. Listen to the show with Mark Cuban (EP418, along with Ferrin Williams, PharmD, MBA), who started a pharmacy called Cost Plus Drugs. Get it? Their prices are cost plus. You have had other pharmacies for years doing similar things, like Blueberry in Pittsburgh. They get the drug. They buy it from a wholesaler or etc. But they buy the drug for some price, and then they sell it to their customers (ie, patients) at their cost plus. But most of the time in pharmacy supply chain world, things don't work that way because many patients have insurance. When a patient walks into the pharmacy, someone has to figure out how much the patient owes and how much their insurance will cover, right? So, enter PBMs (pharmacy benefit managers). They originally started out doing this math (ie, adjudicating claims), figuring out what the out-of-pocket will be for the patient and then what the insurance will cover. Then drugs started to get really expensive and a few other developments, and then, all of a sudden, we have PBMs negotiating with Pharma for how much of a rebate the PBM is going to demand for the PBM to put the manufacturer drug on formulary. The PBM also is determining how much they will pay the pharmacy for said drug on behalf of plan sponsors, in addition to doing the math for how much the patient will pay. So, let me say that again because it kind of begs a “what now?” with eyebrows sky-high as the appropriate response to what I just said, especially if you think through the ramifications here, ramifications which I discuss at length with Vinay Patel (EP241); Benjamin Jolley, PharmD (EP422); Scott Haas (EP365); Paul Holmes (EP397); and others. So, again, the PBM is not just adjudicating claims. They are also negotiating rebates from Pharma so plan sponsors do not have to pay the full amount that the wholesalers paid Pharma and that the pharmacies paid the wholesalers, which maybe is a lot of money. The PBMs are like, “Hey, Pharma. You need to give me a piece of your action because we, the PBM, have big market power. I serve 100 million patients or something. So, if you want access to my 100 million lives, you gotta shell it out. You gotta shell me out some rebates.” So, fine, Pharma gives the PBM some amount of money in the form of a rebate. And it has to work that way, if you think about it, because the drug was originally sold to the wholesaler. You see what I'm saying? So, the pharma company has to give the PBMs a separate rebate amount. This is in addition to how much the PBM told the plan sponsor the plan sponsor owes for the drug, which is also paid to the PBM. But now, PBM is also still in charge of adjudicating the claim. So, they're telling the pharmacy how much to charge the patient. Somehow or another also, the PBM also got itself in charge of deciding how much money the pharmacy itself would be reimbursed by that PBM. In the rest of the world, the pharmacy might tell the PBM, “Hey, this is the price.” But not in pharmacy supply chain world. In pharmacy supply chain world, the PBM tells the pharmacy how much it's gonna pay. The end. And this, my friends, is how so often pharmacies get themselves in the pickle of having to pay the wholesaler one price to get the drug while they get reimbursed a totally different price to dispense the drug. And because independents have very little negotiating leverage on actually either side of that equation, they so very often buy high and sell low. Please listen to the shows with Benjamin Jolley (EP422) and Vinay Patel (EP241), where we get into this in a lot of detail. But I just want to emphasize this point: All of that whole drug supply chain I just went through, where the manufacturer sells to the wholesaler who sells to the pharmacy and the PBM pays the pharmacy and the patient is paying something and the plan sponsor is paying something—many of the middleman transactions in there happen under the cover of darkness a lot of times. If I'm a plan sponsor, do I have any idea how much the PBM paid the pharmacy for any particular drug? Unless you're good at looking at the NADAC numbers (more on this coming up), no. I do not have any idea what a fair price for that drug actually is and how much people are making on the back of that drug as it goes through the supply chain. And this, my friends, is how come spread pricing can exist. Because spread pricing is when the PBM charges the plan sponsor more than they are paying the pharmacy, pocketing the difference, and then calling what they pocket a trade secret—even if it's the plan sponsor whose butt is on the line to make sure that what the PBM is pocketing is fair and reasonable compensation. I mean, if only J&J had listened to this show (EP428). Here's a link to the lawsuit, which is about J&J paying ridiculous amounts in spread pricing. If what I just said is really confusing, I'm gonna validate that and say, “Yeah, it is really confusing.” And to a certain extent, that might be the main point. Where there's mystery, there's margin and all of that. Here's what Dawn Cornelis said on LinkedIn in response to an article about the lawsuit: “Data accessibility lies at the heart of mitigating a fiduciary lawsuit. It all begins with gaining access to your data. But let's be clear—it's not an easy feat. The major hurdle? Procuring accurate data from your TPA [third-party administrator]. And that's just the first step. The subsequent challenge involves analyzing this data, a task best handled by a skilled healthcare data analyst—yet another formidable undertaking.” The one acronym in this whole stew that is not questionable at all is the NADAC. So, let's talk about the NADAC for a moment, the National Average Drug Acquisition Cost Price Benchmark. I was really thrilled to get Luke Slindee to be my guest today—or one reason I was so thrilled—is because Luke works for the accounting firm who, on behalf of CMS (Centers for Medicare & Medicaid Services) and the federal government, administers this NADAC, the National Average Drug Acquisition Cost. (Here's a good NADAC explainer if you're interested.) In brief, NADAC was jointly developed by the Centers for Medicare & Medicaid Services, and it calculates the average price that pharmacies pay for prescription drugs. NADAC is based on a retail price survey. My guest today, as aforementioned, is Luke Slindee. He is a second-generation pharmacist. His family owned a pharmacy in Minnesota when he was growing up. Now he is a senior pharmacy consultant for Myers and Stauffer, which is the accounting firm that calculates the NADAC Price Benchmark on behalf of CMS and the federal government. Also mentioned in this episode are Mark Cuban; Ferrin Williams, PharmD, MBA; Blueberry Pharmacy; Vinay Patel; Benjamin Jolley, PharmD; Scott Haas; Paul Holmes; Dawn Cornelis; Capital Rx; Myers and Stauffer LC; Adam Fein; Joey Dizenhouse; Steven Quimby, MD; and Antonio Ciaccia.   For additional information, go to data.medicaid.gov. You can also follow Luke on LinkedIn.   Luke Slindee, PharmD, is a second-generation pharmacist with a background in independent pharmacy, chain pharmacy, data analytics, and prescription drug pricing. He currently supports public drug pricing transparency benchmarks and is an advocate for pharmacy reimbursement reform and antitrust enforcement in healthcare.   09:52 Why is it important for plan sponsors to understand the going rate for every point in the supply chain? 10:21 How do manufacturers come up with a list price? 10:40 What does AWP stand for? 10:59 What does WAC stand for? 11:06 How are AWP and WAC numbers chosen by the manufacturer? 13:22 What is the difference between AWP and WAC? 14:54 How much are wholesalers paying to manufacturers? 16:43 How much is the pharmacy paying for branded drugs from a wholesaler? 17:34 Why might pharmacies be buying drugs for less than what wholesalers are paying? 18:17 Substack article by Benjamin Jolley, PharmD, on this topic. 19:22 EP423 with Joey Dizenhouse. 20:33 Why do things get weird when a PBM gets involved? 21:58 How does all of this work for generic manufacturers? 25:20 EP344 with Steven Quimby, MD. 26:15 How did Civica Rx come about? 32:21 What's the difference between the NADAC and the AWP value? 36:04 Luke discusses the downstream effects to pharmacies.   For additional information, go to data.medicaid.gov. You can also follow Luke on LinkedIn.   Luke Slindee discusses #followingthedollar through #WAC, #AWP & #NADAC on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392)

This episode is sponsored by Eckard Enterprises. To start empowering your financial future, visit www.EckardEnterprises.com In this podcast segment, Jon discusses the recent announcements from CMS (Centers for Medicare & Medicaid Services) regarding new guidelines for 2024. He highlights a global reduction of 1.25 in overall payment rates, affecting various medical specialties.  Despite the decrease, there are significant increases for primary care and direct patient care services.  Jon emphasizes the importance of staying informed about CMS changes, as they can impact compensation structures and contract terms for healthcare professionals.  He encourages listeners to reach out to Contract Diagnostics for assistance in understanding and navigating these shifts, ensuring that physicians have a voice in negotiations and are fully aware of the implications for their practice. Jon invites individuals to contact Contract Diagnostics through phone, chat, or email for personalized assistance, visit www.ContractDiagnostics.com

When do you need to enter into the Self-Referral Disclosure Protocol (SRDP)? In this episode, Captain Integrity Bob Wade talks the notable settlements and timing under the SRDP. Hear how the CMS (Centers for Medicare and Medicaid Services) is investing greater resources to review and settle these Stark Law violations, why it can be a long process, why it's advantageous to enter the protocol process, how to do so, and the record-setting numbers tied to the SRDP. Learn more at CaptainIntegrity.com

In this original What the Dementia episode, we will discuss the newly announced Medicare dementia care model called the GUIDE Model (Guiding an Improved Dementia Experience Model) by CMS (Centers for Medicare & Medicaid Services). This episode provides insights and details about this model, focusing on what caregivers of individuals with dementia need to know. This episode will cover: — Introduction to the new GUIDE Model for dementia care under Medicare — Qualification criteria for beneficiaries — Roles in the interdisciplinary care team — Detailed breakdown of care services — Key thoughts and takeaways about the model CMS Information on the GUIDE Model https://innovation.cms.gov/innovation-models/guide Alzheimer's Association 24/7 Helpline | 1-800-272-3900 then Dial 711 to connect with a TRS operator. Bambu Treehouse Waitlist | ⁠⁠⁠⁠https://letsbambu.com/treehouse ⁠⁠⁠ LET'S CONNECT: LinkTree | ⁠⁠⁠⁠https://bambu.care⁠⁠⁠⁠ Newsletter | ⁠⁠⁠⁠https://www.letsbambu.com/newsletter⁠⁠⁠⁠ Free Community | ⁠⁠⁠⁠https://www.letsbambu.com/champions⁠⁠⁠⁠ MUSIC CREDIT: Listen To SpillageVillage - Tropical Landing Pop Songs At Looperman.com DISCLAIMER: The information contained in Bambu Care LLC's website, blog, emails, programs, services and/or products is for educational and informational purposes only. While we draw on our prior professional expertise and background in other areas, you acknowledge that we are supporting you in our role exclusively as a Dementia Care Consultant. By participating in Bambu Care, LLC's website, blog, emails, programs, services and/or products, you acknowledge that we are not a licensed psychologist, professional counselor, or medical doctor. We in no way, diagnose, treat, or cure any illnesses or diseases. Dementia Care Consulting is in no way to be construed or substituted as psychological counseling or any other type of therapy or medical advice. The information provided by Bambu Care, LLC also does not constitute legal or financial advice nor is intended to be. Dementia Care Consulting is not a substitute for the services of a CPA or attorney. --- Send in a voice message: https://podcasters.spotify.com/pod/show/whatthedementia/message

Physicians and other senior-serving professionals trying to operate within the complicated Medicare ecosystem must be constantly learning, as the landscape, rules, tools, and vendors are in constant flux. We interview eldercare and Medicare industry experts, do deep dives into their companies, services, and experiences, and share their stories and insights with you. - The Mastering Medicare Podcast is back from a long hiatus caused by both hosts taking W2 jobs during the COVID-19 pandemic. - During their time away, they learned a lot about the changing landscape of Medicare, especially with the rise of AI and value-based care models. - Value-based care was a particular focus in the discussion, with Dr. Mohseni sharing his experiences working at Optum and learning about the value-based care model, particularly within Medicare Advantage. - Value-based care is touted as the future care model for the US healthcare system. It aligns incentives for patients, providers, and health plans, reducing waste and delivering more effective care at lower costs. - The co-hosts contrasted value-based care with the fee-for-service model, pointing out that value-based care requires all parties to be financially invested in patient outcomes, incentivizing efficiency and effectiveness in care. - They also highlighted the importance of collaboration and communication in value-based care, contrasting it with the disjointed nature of fee-for-service care, where different health providers often work in silos. - An example of effective communication was shared from Dr. Mohseni's time at Optum, where real-time notifications were used to coordinate care for patients who arrived at the emergency department, leading to better outcomes for the patients and more efficient care delivery. - The speaker expresses curiosity about why the value-based healthcare system isn't prevalent, considering its beneficial aspects, such as better access to specialists and greater collaboration between healthcare providers. - Questions are raised regarding the incentives for primary care doctors to transition from the regular fee-for-service model to a more complex value-based model, with no clear motivation at the moment. - The discussion mentions gradual efforts by Medicare and CMS (Centers for Medicare and Medicaid Services) to encourage a move towards value-based healthcare, through strategies such as upside gain, share upside models, and ACOs (Accountable Care Organizations). - The Medicare Advantage (MA) model, which has been fully at risk for some time, is described as an effective example of a value-based system. - The complexity of intermediary programs in the fee-for-service model is noted, as many providers either can't understand the rules or choose not to participate due to the complexity. - The speaker then elaborates on the workings of MA plans, wherein health plans are paid by the federal government per member per month to take full global risk on a patient for all of their professional medical expenses. - These MA plans then delegate this risk to a selected medical group, which then uses the allocated funds to manage the patient's healthcare. The remaining difference between the allocated funds and actual healthcare costs becomes the medical group's profit. - This model incentivizes medical groups to keep patients healthy and manage their costs efficiently. - The allocation of funds enables medical groups to acquire services like dieticians or care managers, which are often missing in the traditional fee-for-service model. This allows for a more holistic, patient-centered approach to healthcare. - The conversation discusses a situation where a patient contacts their doctor's office after hours, and rather than being directed to the emergency room, the doctor is willing to solve the issue over the phone. This is because the doctor is being compensated monthly, rather than by individual visits or treatments. - It is stated that any company can start a Medicare Advantage (MA) plan and people can sign up for it. However, these companies often contract with groups like Optum to handle the provision of care. This is paid for by a fraction of the funding that Medicare provides to the MA plan. - Doctors are incentivized to provide extra value in their services and keep costs low because they receive a chunk of money to provide the necessary services, and they keep the difference of what they don't spend. - In the case of a patient with more serious health conditions, a system of risk adjustment is in place. This means that doctors annually document the patient's conditions, which contributes to their Health Condition Category (HCC) score. The higher the score, the more funding the medical group receives. - The conversation suggests that the Medicare Advantage world has been increasingly focused on risk adjustment, given its substantial impact on revenue. However, this has raised concerns about gaming the system and potential fraud. - In the future, it is suggested that there will be a greater focus on better patient outcomes and coordination to maintain profit margins, rather than on risk adjustment. This is expected to spur innovation and the creation of improved solutions for patients. - The conversation discusses the idea of reducing healthcare utilization with a focus on reducing Emergency Department (ED) visits and hospitalizations. - The speakers note that much of the current thinking centers on reducing the need for hospital care through better patient services, new tech, and addressing social determinants of health. - Two additional areas of potential reduction in healthcare spending are identified: pharmacy (particularly unnecessary use of expensive brand name drugs when generics would suffice) and unnecessary surgeries or inefficient surgical procedures. - The speakers emphasize that a lot of care currently delivered in hospitals could be effectively and more cost-efficiently delivered at home. - The conversation then transitions to discussing how the home-based care trend can connect with value-based systems and the opportunities for innovation this brings. There's a focus on how different players in the healthcare system (from family caregivers to healthcare professionals to tech innovators) can collaborate to improve patient care. - They mention the establishment of Medicare Advantage (MA) programs, where healthcare groups receive a capitated payment from Medicare based on a patient's Health Condition Categories (HCC) score. - The speakers then introduce a new initiative, AgingHere.com, a newsletter focused on facilitating a community around aging in place and home-based care. They invite ideas and stories from their audience to share in this platform.

In this episode, you're gonna learn about Emergency Preparedness and the importance of having a good emergency plan - just in case there's a disaster. And you'll learn that sometimes, it doesn't take much to activate an Emergency Preparedness plan.  My guest, Lilia Bolgov, is not only a Registered Dietitian, she's one of my best friends and has a lot of experience in emergency planning. She's the perfect person to share the ins and outs of Emergency Preparedness.  This is what you'll learn in this episode:  Inventory management and planning for emergencies - what to have on hand and how much Different food options when planning a disaster menu Technology and how it can be impacted in a disaster Safety plans for emergency preparedness Why communication is so important Utilities during disasters Here's a glance at this episode:  [05:05] Inventory management for emergency planning [05:43] The different types of disasters that can activate an emergency preparedness plan [08:15] CMS (Centers for Medicare and Medicaid Services) requirements for emergency preparedness and local guidelines [09:10] The general requirements for amount of inventory to have on hand [10:00] A helpful tool that helps facilities determine the forecasted amount of people to include in a disaster plan (emergency preparedness plan) [16:35] Water requirements in an emergency preparedness plan [20:25] The impact of emergencies on technology in an era where we're heavily dependent on technology [23:35] Why it's important to have a clearly written, concise downtime procedure and emergency plan [25:18] The importance of utilities during emergencies  [33:00] Safety plans in emergency preparedness and what to include [34:20] Lilia shares a story of when an emergency plan was activated - what the disaster was and how the department responded to the emergency And I give a shout out to another RD who just passed the exam. This community keeps growing and I'm so proud of all the new RD's.

Pooja Babbrah, Point-of-Care Partners Payer & PBM Lead kicked off the episode by acknowledging guest, Dr. Steven Lane, Chief Medical Officer with Health Gorilla and Point-of-Care Partners co-host, Jocelyn Keegan , Payer/Practice Lead and HL7 Da Vinci Project Program Manager. Pooja then outlined the discussion for this episode. The hosts talked with Dr. Lane about: Trusted Exchange Framework and Common Agreement (TEFCA)Information blocking…or rather information sharing, Dr. Lane's transition from being part of a large health system to joining the health IT company, Health Gorilla and the different perspectives on innovation and change that come with operating in these quite different organizations. The cycle of innovation and the role of policy. Before jumping into the discussion both Jocelyn and Dr. Lane introduced themselves and explained that over the years they have worked with each other several times through the HL7 FHIR (Fast Healthcare Interoperability Resources) Accelerators with Dr. Lane participating in the Da Vinci Project and Jocelyn serving as the program manager of Da Vinci. Today's hosts, Pooja, Jocelyn and the guest are all interoperability champions and share a passion for leveraging technology to improve healthcare. This episode's guest, Dr. Steven Lane, Chief Medical Officer of Health Gorilla, member of the Health Information Technology Advisory Committee (HITAC) and longtime advocate for interoperability identifies as being a clinician first and that role brought him into the health IT space. Dr. Lane shared that he started using an EHR (Electronic Health Record) back in 1989. Worked on EHR implementation during the 1990's and helped launch one of the first patient portals connected to an EHR back in 2001. He explained that he's had more of an opportunity to engage in health IT throughout his career than most primary care physicians. He explained that the importance of interoperability started to be a real focus starting in 2008 and he had the opportunity to work with HIEs (Health Information Exchanges) and then was invited to take part in an ONC (Office of the National Coordinator) taskforce and just continued to say yes to any the opportunities that have come his way so he could contribute to progressing interoperability. He continued to say that in his view if we're going to fix healthcare, we need to first focus on improving the health of our population. Second, improve the value of the healthcare being provided (reduced costs with optimal outcomes). Third, improve the overall experience of obtaining and delivering healthcare for the patients and for the providers, acknowledging that physician burnout is a real issue. Last, improving health equity. Pooja asked Dr. Lane to share a little more about the mission & vision of Health Gorilla to familiarize the audience.Dr. Lane explained that Health Gorilla started initially by addressing physician burden around lab orders and results. From there, they built a platform and started aggregating data they were exchanging and created a private HIE (Health Information Exchanges). They build a robust record service, master patient index, and then aggregate, normalize and de-dupe the records. The focus really being on data quality and utility. He compared the work to some of the regional HIEs, but Health Gorilla's audience is much broader. Health Gorilla made early connections with CommonWell, eHealth Exchange, Carequality framework – Epic Care Everywhere, with Direct messaging through 3rd party health information service providers (HISPs)Dr. Lane shared that what he found special about Health Gorilla is the commitment to innovation and bringing in more data types like social determinants of health or data from wearables. Pooja then asked Dr. Lane to share his view of TEFCA and why Health Gorilla decided to apply to become QHIN (Qualified Health Information Networks)?Dr. Lane described the history of TEFCA, the initial idea for it being included in the 21st Century Cures legislation. He recalled that while interoperability had been a major focus of policymakers and the industry, providers and other stakeholders were still voicing frustration that they still couldn't access the data they needed. The idea of TEFCA was for it to be an onramp to support all kinds of interoperability, data exchange and use cases. He expressed that he has had to learn patience as things in health IT never move as quickly as one might want. Dr. Lane went on to convey that early on after the announcement of TEFCA, Health Gorilla came out with a public commitment to apply to be a QHIN and be part of a diverse community of regional and national private and not-for-profit entities. He continued that becoming a QHIN for a private company is a big deal. They are inviting government oversight and commit to robust governance, state-of-the-art privacy, security and compliance practices. Health Gorilla is committed to supporting a broad range of cases and user communities like:Health Data UtilityPublic HealthCommunity based social servicesPayer-providerIndividual Access ServiceQHINs (Qualified Health Information Networks) will pursue multiple architectural approaches. Health Gorilla will be a data aggregator and platform. Health Gorilla will leverage TEFCA exchange as they do current HIN (health information networks) exchange to continue to build their secure cloud-based repository of health data with the goal to become the nation's largest and most secure repository of high quality, high utility health data.Dr. Lane likened his vision of the role of a QHIN to that of a dance studio operator. He went on to explain that a dance studio operator creates a safe supportive space for people to come to dance. Different types of people - individuals or groups. Different types of dances – flamenco, ballet, private party. Everyone is invited to creatively use the space within specified constraints to ensure safety and privacy. Pooja followed up to clarify whether Dr. Lane likened becoming a QHIN as more opportunity for innovation. Dr. Lane said that absolutely it does. He explained that TEFCA is supplying a framework or single on-ramp and allows for more innovation in various use cases from treatment to payment and operations to public health. Pooja asked Dr. Lane to talk about TEFCA and FHIR. She explained that there has been some feedback in the industry voicing concern that even with the TEFCA FHIR roadmap there isn't enough alignment between TEFCA and the FHIR community. Dr. Lane responded that many were disappointed that when TEFCA was originally announced there was no mention of FHIR at all but since then the TEFCA FHIR Roadmap was published. Some may not be satisfied with the current roadmap but it's a good step in the right direction.Related to the TEFCA FHIR Implementation guide, Dr. Lane summarized some of the responses explaining that there were 16 commenters – Provider organizations, EHR and other HIT (Health Information Technology) vendors, public health departments, HL7, DirectTrust, HISPs, and othersSome commenters called out the challenges of scale especially around registering and managing endpoints. Others pointed out the need to leverage and align with other work in the FHIR community. Others still pointed out the need to clarify the priority between developing to IHE (Integrating the Healthcare Enterprise) document vs. FHIR exchange for specific use cases.Dr. Lane went on to point out that there has been concerns about “if we build it will they come” but the number of QHIN applicants and the engagement seen with the comments submitted are a great sign that people are engaged with TEFCA.Pooja asked Jocelyn to chime in and share what she is hearing from the FHIR Accelerator community related to TEFCA and FHIR? Jocelyn agreed with Dr. Lane about seeing the level of engagement being a great sign. She added that there is starting to be a little bit of a cultural shift related to thinking about data outside of clinical data and how to use data to support billing, operations and more and how to use FHIR to do some of those things. Jocelyn explained that we're starting to see a lot more traction. After attending the Carequality, Sequoia and eHealth Exchange meetings in DC in December and hearing the cacophony of voices talking about how to make TEFCA a reality and leverage FHIR was amazing. From a community perspective, Jocelyn explained that she is hearing a lot of positive feedback after seeing more real alignment happening with TEFCA and the FHIR community and there seems to be a feeling there is more of an openness akin to what happens in the standards development communities which was a needed next step. Jocelyn went on to say that in the near future the industry will need the volunteers to help pilot some of this work and prove we can move beyond point to point and settle the trust issue through these networks. What will be critical is technology meeting us where we are and solving real business challenges. Ultimately, while documents will continue to be part of certain transactions we really have to strive to get to codified data to get to the level of automation the industry needs. Dr. Lane seconded the notion of piloting now and not waiting until policy deadlines are looming. This is the time test, pilot and work out the bugs. Pooja remarked that it will be interesting to see how Sequoia as the Recognized Coordinating Entity (RCE) of TEFCA decides to engage more closely or not with the Accelerators, specifically FHIR at Scale Taskforce. Then Pooja asked Dr. Lane to discuss the huge transition from working for Sutter health, a huge health system to working with a health IT company. Pooja asked him to explain the different approaches to innovation he's noticed. Dr. Lane acknowledged that it is a big challenge to change the course of the huge ship that is healthcare. Things have evolved over the last 100 years or so resulting in the way healthcare is delivered today and it can be hard to change. Many providers may be resistant to change but then you have big disrupters like telehealth and other innovations that force that change. Dr. Lane explained that he has personally been deeply passionate about health IT and being innovative but for many years, he was the only provider in the room for years. That's starting to shift but if the industry wants to see more engagement and willingness to change by providers, there needs to be the right incentives. The most efficient way to innovate is to have all parties at the table with representation to make sure the work being done is solving the right problems. Dr. Lane expressed that he's been at this for 20-30 years and he has recognized the improvement in the process for standards development, policy changes and innovation with people thinking about how we can do this in a coordinated and repeatable way to gain efficiencies. From a policy perspective, Dr. Lane explained, there will always be a need for carrots and sticks. Pooja then asked Jocelyn to share her perspective on the health systems that are members of Da Vinci and whether there are common attributes/factors that lead some systems to be more open to engaging with standards development and FHIR adoption?Jocelyn shared that before she jumps in she wants to point out that CMS (Centers for Medicare and Medicaid Services) has done a lot over the last decade to move the policy levers shifting the industry from a pay for service to a value-based care. This shift will require real-time interaction from a 60-90-day lag in information in provider systems. Health systems likely to be at the standards development table have recognized this shift to real-time exchange and own and master their own data. Jocelyn explained that one of the big attributes she's seen in health systems who are more engaged in standards development are those that area a little further along in the value-based care journey and have strong partner relationships. A second attribute is having a willingness to go first and help prod their partners to move a little faster. Jocelyn went on to say that it isn't just the big health systems that can engage, APIs will help level the playing field and enable smaller systems to operate more efficiently. She went on to say that sometimes all it takes is an individual with a passion like Dr. Lane to volunteer, come to the table and be willing to speak up and share the challenges they are facing during use case development. Standards development isn't just for big health systems to participate and represent providers, it isn't just for developers and implementers. For valuable work to be done the standards development process needs to understand the real-world problems that need to be solved. There is space for providers, pharmacists, grad students, really anyone in the ecosystem. Pooja made the point that this discussion is really about innovation, there is a role for and intersection of policy and standards development and the importance of stakeholder engagement and participation in these areas. She asked Dr. Lane to share his view of the policy role in innovation. Dr. Lane responded by saying that Jocelyn had it right when she talked about the importance of having different perspectives represented, especially when creating the initial use cases. Dr. Lane went on to say that in his role on HITAC and working on USCDI (United States Core Data for Interoperability). After the first version, other stakeholders were invited to the table to contribute and provide feedback and now there is a repeatable process that is done to update USCDI annually. He added that HL7 has been invited in as well and there is coordination there to ensure implementation guides reflect the latest coming version of USCDI. Pooja responded by saying that policy is really important in moving the industry forward but there is also a solid connection between standards development and policy and that in her role as chair of the NCPDP board, she may be biased, but feels organizations who don't participate in standards development are really missing a big opportunity. HL7 and NCPDP see the value of coordinating and working together and CMS and ONC have made it clear through their roadmaps that standards will be named in coming policy so why not come to the table and make sure your organizational interests are being represented while also working to solve the big, complex issues in healthcare? Pooja then shifted the conversation mentioning that as we close out, we like to ask our guests if they have any final message or calls to action, they want to send to the industry?Dr. Lane responded by saying that he sees TEFCA as a once in a decade opportunity to really take nationwide interoperability to the next level. Right now, the general public probably has no idea what TEFCA is and that there should probably be more of a nationwide, public discourse and awareness so people can move towards it versus being dragged along. Pooja then asked Jocelyn for any concluding thoughts or calls to action she would like to send out. Jocelyn expressed her agreement with Steven, what are you doing to advance us as an industry, we're all consumers of this data and ecosystem. She added that we are at an unprecedented time when the industry is leading and CMS and ONC are playing a critical role in alignment. The standards version advancement process (SVAP) is a notable example of CMS and ONC listening to the industry. They are no longer putting a ceiling on the level of advancement and progress the industry can make but rather focusing on establishing a floor. Jocelyn reiterated her encouragement of organizations and individuals to come and participate in the standards development process and give voice to your challenges so the industry can solve real problems. Pooja thanked cohost and interop expert Jocelyn Keegan and the well-informed guest, Dr. Steven Lane from Health Gorilla And thanks to our audience for tuning in! A friendly reminder to new listeners that you can find us on Apple Podcast, Spotify or whatever platform you use to pick up your podcasts, including HealthcareNOW Radio and the Podcast Channel. We also post videos of our podcast episodes, sometimes longer versions, on the POCP YouTube channel. And don't forget, Health IT is a dish best served Hot!

HRRP stands for Hospital Readmissions Reduction Program, by the way. I wanted to encore this episode with Dr. Rishi Wadhera because it's a great representation of a common root cause reason why quality metrics sometimes don't end well in real life. This root cause is otherwise known as Goodhart's Law, and we dig into Goodhart's law later on in this healthcare podcast. But the actual and ultimate impact of HRRP is also a pretty good representation of the consequences, what happens, when you create a blunt-force policy that assumes hospitals with very different circumstances are the same. Before we kick in to the episode, I asked Dr. Wadhera, my guest today as aforementioned, if there'd been any updates regarding HRRP since this show originally aired last year; and he told me that two key pieces have come out this past month in JAMA journals calling out CMS (Centers for Medicare & Medicaid Services) to move on from/retire this policy: A Decade of Observing the Hospital Readmission Reductions Program—Time to Retire an Ineffective Policy Readmission Reduction as a Hospital Quality Measure: Time to Move on to More Pressing Concerns? Thanks so much to Dr. Steve Schutzer and also BoneDoc66 for your really nice reviews this past month. So appreciated … thank you so much! And here is your encore. Today's guest is Rishi Wadhera, MD, MPP. Dr. Wadhera authored a retrospective analysis in the BMJ about the HRRP, which we will talk about in this healthcare podcast. Dr. Wadhera is a cardiologist at Beth Israel Deaconess Medical Center. He also has a master's in public policy at the Harvard Kennedy School of Government and also a master's in public health from the University of Cambridge. But here's the larger epiphany that pertains to all value-based care and all quality metrics which Dr. Wadhera brings up in this healthcare podcast and which my nerd heart could not love more: Goodhart's Law. This law is the root of so very many problems. Goodhart's Law is this (which I learned from Dr. Wadhera): “When a measure becomes a target, it ceases to be a good measure.” In other words, when we set a goal, people will try to take a shortcut to the goal, regardless of the consequences. And sometimes the consequences, paradoxically, are to do worse at the goal. Maybe because bean counters and admins and maybe even goal-oriented clinicians themselves will go right to the end goal, inadvertently skipping a whole bunch of (it turns out) rate-critical steps. For example, teaching to the test may not lead to students who deeply understand a subject. And anyone trying to achieve value-based care success, improve quality, form collaborations, or make sales might want to remember that old proverb, “Sometimes the shortest way home is the long way around.”   You can learn more at Dr. Wadhera's Harvard Catalyst profile and the Beth Israel Deaconess Medical Center Web site.   Rishi K. Wadhera, MD, MPP, MPhil, is an assistant professor of medicine at Harvard Medical School, a cardiologist at Beth Israel Deaconess Medical Center (BIDMC), and the associate program director of the cardiovascular medicine fellowship at BIDMC. He is also health policy and equity researcher at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology. Dr. Wadhera received his MD from the Mayo Clinic School of Medicine as well as an MPhil in public health as a Gates Cambridge Scholar from the University of Cambridge. He completed his internal medicine residency and cardiovascular medicine fellowship at Brigham and Women's Hospital in Boston. During this time, he also received a master's in public policy (MPP) at the Harvard Kennedy School of Government, with a focus on health policy. Dr. Wadhera's research spans questions related to healthcare access, quality, and disparities, as well as understanding how local, state, and national policy initiatives impact care delivery, health equity, and outcomes. Dr. Wadhera has published more than 80 articles to date, and he receives research support from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institutes of Health (NIH)   03:30 What was the Hospital Readmissions Reduction Program intended to do? 05:22 Why did the Centers for Medicare & Medicaid (CMS) think some readmissions were preventable? 06:02 “The spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve … discharge planning, transitions of care, and post-discharge follow-up and care.” 06:58 How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program? 08:16 “The 30-day readmission measure—it's an incomplete measure.” 11:48 “I think patients … are smart, and they know what's going on.” 13:34 “What's happening is, we're just increasing the number of times they need to come back to the ER within that 30-day period.” 13:55 “The weird thing about the HRRP is that when it evaluates hospitals' 30-day readmission rates, it's a yes-no phenomenon.” 15:03 “What CMS does is, it risk adjusts … and that is what we should be doing.” 18:30 “This program has been incredibly regressive.” 19:04 “Poverty, neighborhood disadvantage, housing instability—these factors are out of hospitals' control.” 21:50 “Blunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.” 22:06 “It just makes no sense to take resources away from hospitals.” 22:32 EP295 with Rebecca Etz, PhD. 23:47 What's the way to improve quality of care globally? 25:37 “CMS's approach to improving quality of care has really anchored … [that] to payment.” 26:08 “It's time for us to rethink what our approach to quality improvement should be.” 29:22 “Policy makers have an obligation to rigorously test the impact of these types of policies before they roll them out nationally.” 31:41 Can you scale healthcare nationally?   You can learn more at Dr. Wadhera's Harvard Catalyst profile and the Beth Israel Deaconess Medical Center Web site.   @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission What was the Hospital Readmissions Reduction Program intended to do? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission Why did CMS think some readmissions were preventable? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “The spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve … discharge planning, transitions of care, and post-discharge follow-up and care.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “The 30-day readmission measure—it's an incomplete measure.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “What CMS does is, it risk adjusts … and that is what we should be doing.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “Blunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “It just makes no sense to take resources away from hospitals.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission What's the way to improve quality of care globally? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “It's time for us to rethink what our approach to quality improvement should be.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission Can you scale healthcare nationally? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission   Recent past interviews: Click a guest's name for their latest RHV episode! Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370)

Medicare Part B enrollees won't be expecting a lower monthly premium this 2022. The standard monthly premium of $170.10 is still enforced but will be lower by 2023.Medicare Part B is available for seniors ages 65 years and above and must be permanent U.S residents or citizens living in the U.S for a minimum of five consecutive years. The coverage includes doctor's visits, outpatient services, and diagnostic tests. With the recent $21.60 premium increase, secretary Xavier Becerra of the U.S Health and Human Services prompted CMS (Centers for Medicare and Medicaid Services) to reassess this current change.One of the reasons for the premium increase is the cost of Aduhelm, an Alzheimer's drug that was recently approved by the FDA and set to be priced at $56K per year which has been highly debated. After much discussion with Biogen, the original cost was reduced to half, estimated at $28,200 per annum as of January 1, 2022. However, the coverage for Aduhelm will be limited to enrollees whose clinical trials are approved.While waiting for CMS to announce the 2023 Part B premium this October 2022, it is decided that it would reflect all of the savings onto those beneficiaries who are eligible for Aduhelm.So, what does this mean for Medicare Part B enrollees? The Part B premium for next year may be lower, however, you can look forward to a potential premium cut in 2023, not 2022.If you're looking for more comprehensive coverage than what Medicare Part B offers, you may consider replacing Original Medicare with a Medicare Advantage plan. Private insurance companies offer Medicare Advantage plans and typically include prescription drug coverage and other benefits like dental, vision, and hearing.Opting for a Medicare Advantage plan to your existing Medicare Part B coverage can help you save money on your overall healthcare costs. And, if you enroll in a Medicare Advantage plan that includes prescription drug coverage, you'll be able to get your medications at a lower price than if you were to buy them separately.Wading through the Medicare alphabet soup can get overwhelming, and that's why various Medicare advisors like Hella Health are here to help you understand your options and make the best choices for your unique needs and budget. Integrating technology to support this new generation of savvy consumers, such digital platforms offer access to clear and concise information so that you can make the best decision for your health.You can look for other helpful information from websites like Medicare to guide you through the process. And when you've done your research, you can work with a Medicare advisor to help you understand your options and find the best plan.For more information, contactstayintheloop@email.hellahealth.com

Medicare Advantage (MA), otherwise known as the “money machine,” is often the most profitable parts of many payers' business lines. Medicare Advantage plans can make a lot of cash if they are good at what they do. Look at any of these large, consolidated carriers' financial statements to get the magnitude of that statement. Also, in 2022, Medicare Advantage plans have enrolled 28 million participants between them, which represents 45% of all Medicare beneficiaries. This marks a three-point improvement in penetration over 2021 and a total program enrollment growth of 9%.   All of this is not a secret. So, what's happening right now is that this administration is looking carefully at Medicare Advantage plans and what they have been up to. We have had an amping up of government oversight, including regulatory actions and program audits. In this healthcare podcast, I am speaking with Betsy Seals, who is CEO and cofounder of Rebellis Group, which is a managed care consulting firm working with Medicare Advantage plans. Betsy says (and this is what we talk about in the interview) that there's three main areas that the government is currently scrutinizing: Sales and marketing. There have been these third parties, it seems, these field marketing organizations who were hired to do marketing and sales for some of the Medicare Advantage plans. And because they were third parties, it seems that many of them felt themselves to be excluded from CMS (Centers for Medicare & Medicaid Services) regulations and able to basically mislead prospective members with sales pitches that were highly suspect. Betsy gives some examples of these, and when you hear them, you will see why CMS is cracking down. Recouping improper payments is another area that CMS is all over. Interestingly, as Betsy Seals says in this interview, this might be one area where the government is actually ahead of private sector plans from a technology and analytic standpoint. CMS seems to have better analytics capabilities and is better at detecting fraud schemes and improper payments than the plans themselves. These plans are not sophisticated enough to notice stuff that CMS detects when it gets ahold of the plan data. But as unusual as this situation is where the government is ahead of the business sector, I can't say I'm shocked. We have had one guest on this show after another talking about just how far in the past some of these health plans are lagging. Dan O'Neill probably said it most eloquently and notably (EP359).   But I digress. So, recouping improper payments has the eye of CMS. This means two things largely. It means finding “outlier” codes that some MA plan paid for but which are clearly errors and should not have been paid. Another improper payment is when plans themselves do a little fancy upcoding so that they make more money than they should in their risk-adjustment payments. This has gotten some major attention lately. Let me quote from an OIG (Office of Inspector General) report:   “Our findings raise concerns about the extent to which certain MA companies may have inappropriately leveraged both chart reviews and HRAs [health risk assessments] to maximize risk-adjusted payments. We found that 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.” The sneaky idea here to get more money than they should from taxpayers is that someone somewhere puts down that a member has major depressive disease because someone somewhere said they did. But the patient clearly doesn't have major depressive disease because they aren't getting any treatment for it and nothing anywhere would indicate that they are suffering from a major depressive disease. So, the plan winds up getting more money from the government to care for a patient who is suffering from major depressive disease, but the patient doesn't require any additional care because they don't have major depressive disease. It's a great way to make some dollars for shareholders that is coming right out of the pockets of taxpayers. In sum, the #2 area of additional oversight is recouping improper payments either from paying claims that should not have been paid for or by wild upcoding. This is just kinda like the general sort of compliance oversight that CMS does, meaning grievances and appeals and formulary administration and models of care for SNP plans (special needs plans), compliance program effectiveness—normal stuff like this—which will be interesting given all of the articles coming out right now about how patients on Medicare Advantage plans are less likely to get more costly diabetes treatments and how often there's denials for cancer care or NCI cancer centers aren't covered, etc. One point of note here that's kind of thought-provoking on a few levels: If you're an MA plan, it is super important for you to get members in for their annual screenings. For one, CMS requires that you document diagnoses each year; and you need to do this to reduce the chances that CMS will question a treatment being paid for because there's no underlying diagnosis to support it—and these diagnoses must be re-upped every year. Recall what I was just talking about re: improper payments and fraud schemes. If a patient isn't diagnosed with something, then why are taxpayers paying for its treatment? Also risk adjustment ... if you wanna upcode, it's not a bad idea to have a diagnosis documented in multiple different ways so that when the OIG/CMS/DOJ comes knocking, you can have your ducks in a row. Getting patients in for their annual screenings is how you can safely upcode. Further, one more reason why getting patients in for annual screenings matters to MA plans, member experience counts for an increasing piece of star ratings. Patients who never see their doctor and never interact with the plan don't usually give the plan they have nothing to do with stellar marks—and besides that, these members are tough to retain. Last big deal for an MA plan to get members in for their annual is this is when the doc gets into screening for care gaps, which is also part of star measures. All this about annual screenings is a bit of a sidebar, but it is kind of interesting to contemplate as we get into the conversation today about government oversight. (For a meme on this topic, check out this Tweet from Rik Renard.) My guest, as I mentioned earlier, is Betsy Seals. Listen to our conversation about how MA plans are in the hot seat right now. Later in the fall, Betsy will be coming back to talk about trends in the Medicare Advantage marketplace. You can learn more at rebellisgroup.com.   Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations. Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations. Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs. Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits. 08:15 What's happening with sales and marketing in the healthcare industry? 11:04 What's happening with the focus on recouping improper payments? 13:32 “When you look at the fundamentals of it, these are federal dollars. And what we're talking about is federal dollars that were paid when they should not have been paid.” 15:39 Are improper claim payments an administrative problem, or something more intentional? 16:20 “The health plan has a responsibility to catch those issues.” 20:10 What are specialty pharmacy prescriptions being scrutinized for? 22:12 “If this is where CMS is headed … the health plan should've already been doing this.” 23:58 Why do you see a bigger focus on social determinants of health? 25:54 Do these health plan audits actually have any teeth? 27:01 What is the biggest penalty a health plan can face from an audit? 29:57 “Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.” You can learn more at rebellisgroup.com.   @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's happening with sales and marketing in the healthcare industry? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's happening with the focus on recouping improper payments? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “When you look at the fundamentals of it, these are federal dollars. And what we're talking about is federal dollars that were paid when they should not have been paid.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are improper claim payments an administrative problem, or something more intentional? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The health plan has a responsibility to catch those issues.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are specialty pharmacy prescriptions being scrutinized for? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If this is where CMS is headed … the health plan should've already been doing this.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why do you see a bigger focus on social determinants of health? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Do these health plan audits actually have any teeth? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is the biggest penalty a health plan can face from an audit? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento  

In one of our most important podcasts released to date, we're proud to talk with Dr. Laurie Whitsel, Vice President of Policy Research and Translation of the American Heart Association & Senior Advisor to the Physical Activity Alliance, a non-profit that, "Brings together stakeholders in the physical activity communities for us to speak with one voice on significant policy and systems changes," states Whitsel.  Joining her is Integrity Square's own Chief Political Architect and policy veteran, Tom Richards, JD who also heads up Activist in Motion. It is critical everyone in the HALO sector know about the work going on behind the scenes in something called the HL7 process (Health Level Seven International) and the steps currently being taken to, "Build standardized measures for assessing, prescribing, and referring physical activity for patients." Concurrent with that is the Time To Move initiative, a multi-year, multi pronged approach which (among other things) involves bringing in and standardizing billing codes for physical activity, connecting wearables so the data can flow and follow the patient through healthcare delivery, but also working with with CMS (Centers for Medicare and Medicaid services) to get coverage determinations for the exercise prescription for health and fitness professionals to offer it and more.   These things are happening now and Dr. Whitsel is the tip of this particular spear. Pete Moore, host of HALO Talks, mentions early on that this is indeed like "moving boulders" but they are moving. . . perhaps further and faster than we all thought.  Policy conversations may not be everyone's particular cup of tea when you have a business to run and 100 other things demanding your attention. However, what Dr. Whitsel discusses here and what is literally happening right now will have incredibly far ranging positive effects for the entire industry-and probably sooner rather than later.  This is one of our longer episodes and we hope you enjoy it as much as we did. All the resources mentioned are available at the links below. Get involved now!  PAA Letter to the White House PAA HL7 Slides PAA Action Plan Click here to download transcript. 

Dr. Jerry Smith welcomes you to the inaugural episode of AI Live and Unbiased to explore the breadth and depth of Artificial Intelligence and to encourage you to change the world, not just observe it!   Dr. Jerry is joined today by Tammy Siragusano who is a veteran in U.S. healthcare reform whose focus has been on the enterprise approach to some of the most complex health care problems facing the industry today. She is experienced in healthcare IT, managed care operations, is a PBM-PBM migration specialist, and takes care of a lot of operational issues. Tammy has also led the digital transformation for clinical logistics for drug and utilization review. In today's episode, she shares her vast knowledge and experience in the field of AI and shares great ideas and suggestions for better AI implementation in the healthcare field.   Key Takeaways: Tammy shares why she got involved in the healthcare field Tammy belonged to the debate team and healthcare was at the center of their attention, a reform was desperately needed due to many delays in the care. Tammy didn't join the healthcare field as a software engineer but as a sports medicine practitioner. Three of the biggest aspects that drive decisions in healthcare: Watch the pennies, the dollars will take care of themselves. What is the most convenient way that the patient can receive the care he/she needs? Where should the focus be to make the biggest long-term impact? Why is AI needed in healthcare? Technology has to find a way to disrupt the status quo. Health practitioners need to focus on patient care. One-third of healthcare practitioners are already using AI and almost one-half of the other companies are currently exploring it. What kind of problems is healthcare trying to solve through AI? Upcoding and regulatory sides are two of the major fields where AI is needed. AI can make payments easier. There are three obstacles to AI implementation in the healthcare industry: limited resources, different data that is unconnected, and lack of tools and platforms to develop solutions. CMS (Centers for Medicare and Medicaid Services) set aside a considerable amount of money for technology companies to use for innovations. Budget is not an issue; the government will fund projects that develop platforms to create solutions. What are the biggest problems to focus attention on? There are performance improvement plans for clinical groups that will be based on outcomes; not only they will have to be doing better but be able to prove it since the reimbursements will depend on it. Call centers collect very important patient information that could be utilized more effectively with the help of AI. AI could identify how the patient feels when calling and identify the level of urgency of the call. What does the future of wearable medical devices look like? Wearable medical devices will get better and better. Wearables will help those who are currently restricted in their abilities because of a disease or characteristic of their body. Tammy talks about the possible uses of AI for prescription monitoring. There are outreach programs to follow up on how patients are taking their prescription medicine, for them to stay on track with their medication, and find out the reasons why some people are not. Where do we go from here? The government is looking to fund great ideas, they are looking for creativity and new technology from the AI world.   Stay Connected with AI Live and Unbiased: Visit our website AgileThought.com Email your thoughts or suggestions to Podcast@AgileThought.com or Tweet @AgileThought using #AgileThoughtPodcast!   Learn more about Dr. Jerry Smith   Mentioned in this episode: CMS

This episode provides an in-depth analysis of Friday's Supreme Court hearings on the Biden administration's contested COVID-19 regulations set separately by OSHA (Occupational Safety and Health Administration) Emergency Temporary Standard covering employers with 100 or more employees and CMS (Centers for Medicare & Medicaid Services ) Emergency Regulation covering healthcare workers.

Join Health Affairs Insider.With 2021 about to be in the rearview mirror, Health Affairs' Jessica Bylander and Ellen Bayer gather on Health Affairs This Week to quickly chat about some of the biggest developments in health policy for the year.Looking back, they talk about the Biden administration's health agenda - which includes a focus on health equity and innovation - as well as the Build Back Better measure, how infrastructure relates to health policy, and where we move from here.Related Links: Innovation At The Centers For Medicare And Medicaid Services: A Vision For The Next 10 Year (Health Affairs Blog) A Strategic Vision For Medicaid And The Children's Health Insurance Program (Health Affairs Blog) How the House Spending Bill Would Expand Health Care Benefits (The Washington Post) Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government (White House) My First 100 Days and Where We Go From Here: A Strategic Vision for CMS (Centers for Medicare and Medicaid Services) Subscribe: RSS | Apple Podcasts | Spotify | Castro | Stitcher | Deezer | Overcast

Recently I was talking to someone, a civilian not in health care, and I mentioned something about how patients don't always get a treatment plan (a care plan) based on the best evidence or sometimes even any evidence. Here's how I explained it to him—what this looks like in the real world: Let's say two patients, patient 1 and patient 2, with the exact same clinical needs and zip code … both these two patients see the exact same doctor. The only difference between these two patients is that they're two different colors. And let's add a third patient into this mix: say, ME. Let's say I have the exact same profile and zip code as those first two patients. I see a different clinician in the same exact practice, though. In all these circumstances, evidence is evidence, right? There should be one care plan that all three of us get when we show up at that same care setting. Until the evidence changes, that is, right? But the reality is that it's just as likely that those other two patients and I, we all get various shades of different care plans. The civilian I was having the original conversation with about evidence-based medicine and this care planning? He literally recoiled in surprise. He was shocked. He said he thought medicine was more science than that. I'm going to take that anecdote as a data point to suggest that there is a disconnect between what patients think is going on and what is actually going on relative to how care plans tend to happen in health care. Alex Akers from Health Catalyst in episode 176 and Clint Phillips from Medici in episode 201 get into this in detail. You can listen to full episodes and learn more about this week's guests at relentlesshealthvalue.com.  Jeffrey Hogan is the northeast regional manager for Rogers Benefit Group, a national benefits marketing and consulting firm. Jeff has been with Rogers Benefit Group for 30 years. Additionally, Jeff operates a consulting firm, Upside Health Advisors, where he provides expert witness services on health care–related litigation, is a consultant to payers and large provider groups for product development and launch, and is a resource to employers desirous of implementing strategies to manage their health spend. Jeff is focused on health care payment reform, health policy, care coordination, value-based health care, health care quality, and precision medicine. Jeff regularly appears on national forums focused on moving to value-based health care and is actively working to promote health care–related transparency measures in the market. He serves as the group's liaison to the National Alliance of Healthcare Purchaser Coalitions. Jeff is the regional leader for The Leapfrog Group. He is also one of the coordinators of Connecticut's Moving to Value Alliance. Darrell Moon founded Orriant in 1996 to change the dynamics of health care and give employers some control over the ever-increasing costs of the health care benefits they offer their employees. Darrell believed that engaging individuals in the management of their own health was a key that had to be inserted back into the economic equation of health care. Darrell received both his bachelor's degree in finance and his master's degree in healthcare administration from Brigham Young University. As the CEO, COO, or CFO, Darrell managed medical and psychiatric hospitals throughout the country for over 10 years prior to creating Orriant. He also has more than a decade of experience managing insurance and managed care products. Darrell is a Forbes leadership contributor. Grace E. Terrell, MD, MMM, is CEO of Eventus WholeHealth, a company focused on integrated value-based behavioral medicine and primary care in the long-term care space. She is a national thought leader in health care innovation and delivery system reform and a serial entrepreneur in population health outcomes driven through patient care model design, clinical and information integration, and value-based payment models. She is the former CEO of Cornerstone Health Care, one of the first medical groups to make the “move to value” by lowering the cost of care and improving its quality for the sickest, most vulnerable patients; the founding CEO of CHESS, a population health management company; and the former CEO of Envision Genomics, a company focused on the integration of precision medicine technology into population health frameworks for patients with rare and undiagnosed diseases. Dr. Terrell currently serves on the US Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Committee and the board of the AMGA (American Medical Group Association), is a founding member of the Oliver Wyman Health Innovation Center, and is the coauthor of Value-Based Healthcare and Payment Models. Rich Klasco, MD, FACEP, has focused throughout his career on rendering evidence-based medicine operational—that is, making the right thing the easy thing to do. He has pursued this goal in academia, in industry, in policy, and in the press. In addition to publishing extensively in both peer-reviewed journals such as JAMA and lay publications such as The New York Times, Dr. Klasco has taught at leading academic medical centers, including Harvard, Stanford, Mayo, and the University of California, San Francisco; served on the executive committee of Brigham and Women's Hospital Center for Patient Safety Research and Practice; testified before the United States Congress on evidence-based practices; and won CMS (Centers for Medicare & Medicaid Services) approval for an officially designated compendium of evidence-based oncologic drug information. Dr. Klasco previously served as chief medical officer and editor-in-chief for the Thomson Reuters group of health care companies, where he had editorial responsibility for companies including Micromedex, the Physicians' Desk Reference (PDR), and the United States Pharmacopoeia (USP) Drug Information. For the past 15 years, Dr. Klasco has served as chief medical officer for Motive Medical Intelligence, where he provides clinical leadership for the development and deployment of solutions that quantitative assess physician performance for payers, providers, and patients, and integrate scientific knowledge into workflow systems where it can be accessed and applied in real-time. Dr. Klasco received his medical degree from Harvard Medical School. He completed his internship and residency in internal medicine at Brigham and Women's Hospital, and he completed his residency in emergency medicine at the Denver Health Residency in Emergency Medicine, where he served as chief resident. Nicole Bradberry is the founder and chief of growth and innovation officer for MIND 24-7. MIND 24-7 runs mental health crisis centers with a focus on immediate access, quality care, and the understanding that mental health and substance abuse drive significant health cost. She is also the founder of ValueH Network, which aggregates high-performing value-based care network providers in order to enable the best performance in new innovate contracts. In addition, she is currently the chief executive officer and chairman of the board of the Florida Association of ACOs (FLAACOs). FLAACOs is the premier professional organization for accountable care organizations (ACOs) throughout Florida which provides education and collaboration in the fee for value health care space. Nicole spent 16 years leading operations and information technology programs for UnitedHealth Group and Cigna HealthCare. While there, she served as business lead for the technology transformation of the country's largest dental and vision services company, led the national deployment of health care quality and affordability programs, and was responsible for the successful integration of many major health plans. Nicole holds a bachelor's degree in statistics from the University of Florida. She has been recognized for her personal and professional achievements many times, recently as the nation's Outstanding Midmarket IT Leader of the Year and one of the Business Journal's “Women of Influence.” She is often found on the speaker faculty for health care conferences focused on ACOs, population health, and value-based care. She is passionate about changing health care and enabling physicians to provide high-quality, cost-effective, and consumer-focused care. Kelly A. Conroy is director of Pinnacle Healthcare Consulting and brings more than 30 years of health care finance, management, and leadership experience with significant experience in value-based care. As a leader in the field, she'd contributed through multiple start-up health care companies with a leading-edge focus on advancements in care delivery and alignment. Kelly started the first Medicare ACO in the country, which delivered nearly $40 million in savings in its first year and has gone on to manage some of the most profitable ACOs in the country. She is now sought after as a senior advisor and consultant, having developed a reputation as one of the most experienced and effective ACO professionals in the country. As a true catalyst driving the shift in health care culture toward physician leadership, her understanding and strategic vision are unmatched, along with her comprehension of the latest government-proposed valued-based agreements. From starting health care organizations to serving in multiple senior executive leadership roles, Kelly is a seasoned executive with a career record of negotiating and increasing revenues through new product offerings while optimizing efficiency and productivity in the medical field. 02:10 Jeff Hogan (EP309) talks about the consequences of when there's a disconnect between what the patient thinks is happening and what is actually happening in a care plan.03:48 EP315 with Bob Matthews. 03:58 Merrill Goozner's perspective on successful population health.04:55 Why did Darrell Moon (EP305) give up being a hospital administrator because of care plans? 08:02 “It's a myth that population medicine … and precision medicine are incompatible or opposites.”—Dr. Grace Terrell (EP319) 11:28 Dr. Rich Klasco (EP321) explains “noncognitive” medicine and why it bogs physicians down.14:45 What is at the core of appropriateness for care? 16:33 “You start to bring that data to the physician, and it really does open their eyes.”—Nicole Bradberry (EP324) 16:51 Nicole Bradberry and Kelly Conroy (EP324) discuss how to really change the way physicians work. You can listen to full episodes and learn more about this week's guests at relentlesshealthvalue.com.  Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the consequences when there's a disconnect between what the patient thinks is happening, and what is actually happening in a care plan? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth Why did Darrell Moon give up being a hospital administrator because of care plans? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “It's a myth that population medicine … and precision medicine are incompatible or opposites.” Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth What is “noncognitive” medicine, and why does it bog physicians down? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth What is at the core of appropriateness for care? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “You start to bring that data to the physician, and it really does open their eyes.” Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth How do you really change the way physicians work? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry, Dr Douglas Eby (EP312), Ge Bai, Sumit Nagpal, Dr Vikas Saini and Shannon Brownlee

2/3rds of Americans who file bankruptcy actually cite medical issues as a key or main contributor to their financial downfall? That’s roughly 530,000 American families a year. Nation, glad you’re here and welcome to another episode of Healthcare360, the only Healthcare podcast, where you can listen to both sides of the story, fairly! Folks, this medical bankruptcy discussion has to be addressed, so we decided to tackle this topic in three parts. In part one of the discussion, Roger Jansen a Neuropsychologist and Chief Science Officer for a $6B healthcare system shares his experience and insights surrounding the pitfalls of the current business model of healthcare, and the radical disruption needed before significant improvements can be made. You will be shocked by the stats you will hear in this episode, it’ll probably upset you at the same time. Yet my hope is that this conversation will be built on, continued to be discussed, and we all become aware and better informed patient consumers moving forward. Thank you for being open minded and curious about our healthcare options! Healthcare360 Host: Scott E. Burgess www.ScottEBurgess.com Burgess@ScottEBurgess.com youtube.com/healthcare360withscotteburgess Healthcare360 Magic Maker: Michelle Burgess MagicMaker@ScottEBurgess.com Guest Info: Roger Jansen, PhD linkedin.com/in/rogerjansenphd Healthcare 360 Affiliates: The Root Brands: https://www.therootbrands.com/healthcare360, create an account and add Healthcare360 in the referral code BodyChek Wellness: https://www.bodychekwellness.com/ PROMO CODE: Healthcare360 at checkout for 20% off all purchases. VoxxLife: https://healthcare360.voxxlife.com/ Referenced Links: CNBC Article: This is the real reason most Americans file for bankruptcy by Lorie Konish https://www.cnbc.com/2019/02/11/this-is-the-real-reason-most-americans-file-for-bankruptcy.html HC #073 Future of Healthcare - this Medical Futurist's Vision with Dr. Mesko https://youtu.be/xAjVzAzcfvE HC360 #064 Wake Up Call for MedTech with CEO Joe Mullings of The Mullings Group https://youtu.be/AXRlDLod_E0 HC360 #035 The Rapid Change of Healthcare with CEO Lonny Stormo https://www.scotteburgess.com/podcast-episodes/the-rapid-change-of-healthcare-with-ceo-lonny-stormo CMS Centers for Medicare & Medicaid Services https://www.cms.gov/ OECD Organisation for Economic Co-operation and Development http://www.oecd.org/unitedstates/ The Price We Pay by Dr. Marty Makary https://www.amazon.com/Price-We-Pay-American-Care/dp/1635574110 HC360 #071 Body's Great RESET! Therapeutic WATER-Only Fasting to naturally heal your body: Dr Alan Goldhamer https://youtu.be/NQ30X2WpUWw HC360 #068 The Truth About Virus & Bacteria with Dr. Tom Cowan https://youtu.be/9NB3e8dfvEU Music provided by: IMMEX - Blue Shark https://www.youtube.com/watch?v=r1pmz9IJ1CA Graphic Design by: Waqar Mughal waqarstudio92@gmail.com Disclaimer: The information provided is for educational purposes - not intended as medical advice. It is always the advice of Healthcare360 to consult with a doctor or other health care professional(s) for medical advice. Some of these links go to one of my websites and some are affiliate links where I'll earn a small commission if you make a purchase at no additional cost to you.

Medicare Advantage (MA) enrollment has nearly doubled over the past decade. It grew 37% from 2016 to 2020. Right now, MA comprises nearly 40% of the Medicare population—and that number is only expected to grow. So, in case you’ve been out of the loop, at the beginning of 2020, CMS (Centers for Medicare & Medicaid Services) rolled out a third category of these “chronic supplemental benefits.” And these chronic supplemental benefits allow plans to offer basically services to attenuate social determinants of health to offer stuff like nonemergency transportation, meals, home modifications … that whole list. This is all, really, part of a broader bipartisan effort to move Medicare from an acute care to a chronic care program. Then … corona. So, the question I’m kind of wondering about at this juncture is, Were/Are MA beneficiaries able to maintain their health status better than, say, other plan designs, especially given some of these chronic supplemental benefits, which you’d think would be super helpful in the middle of a pandemic? This should make sense, and it should really be true. At its core, MA is, as John Gorman put it when he was on the show last year, the biggest value-based payment experiment in the universe. And patient outcomes have definitely improved for MA patients over traditional FFS (fee for service), especially in the south and in other areas rife with cardiovascular and metabolic disease. So, that sounds great. Now let’s talk about the cash money denominator in the value equation. Humana reported $1.8 billion in profit for the second quarter. That was nearly double its haul in Q2 2019. So far, 2020 has seen a profit that is a 94.5% increase year over year. Humana’s earnings are not an outlier. MA plans across the board did very well, thank you very much, in the middle of a pandemic. Given that MA hasn’t actually reduced PMPM (per member per month) costs last time I looked at it, you’d think and hope that the confluence of higher rates and less restrictions on extra benefits should definitely lead to greater scrutiny on the plans by CMS. We’ll see what happens. Anyway, it occurred to me that it might be interesting to get a bead on what MA plans themselves have been contemplating and thinking about relative to the supplemental benefits et cetera. In this health care podcast, I speak with Betsy Seals, cofounder of the Rebellis Group. Betsy spent many years working with and for Medicare Advantage plans. I thought Betsy would be the perfect person to talk to to get a bead on what’s happening on the MA front right now. You can learn more at rebellisgroup.com. Betsy Seals is a cofounder and chief operating officer at Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage organizations and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 18 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the Medicare landscape. Betsy’s expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that addresses social determinants of health, and health plan operations. Betsy got her start in managed care on the health plan side, where she held roles in compliance and operations. Betsy also spent many years as a managed care compliance and operations consultant with Gorman Health Group, where she exited as chief consulting officer in the fall of 2018. 03:45 What is a Medicare Advantage plan? 04:02 The core imperatives for leaders of Medicare Advantage plans. 04:31 “How is risk adjustment functioning?” 04:34 Making disenrollment rates and member complaints top of mind for MA leaders. 05:40 “We all want to know why members are leaving. Well, they’re telling you!” 05:50 Star rating measures. 07:33 “Will Medicare beneficiaries really have confidence … going into the doctor’s office … next year?” 09:11 “Now, it’s not just ‘Is your doctor in the network?’ It’s ‘Does your plan also offer telehealth?’” 12:13 “When you really look at Medicare beneficiaries aging into the program or … younger … beneficiaries, their shopping trends and their consumer expectations are very much the same as yours and mine.” 13:58 CMS’s adjustment in April that allows MA plans to make changes to their benefits midyear to provide to beneficiaries’ changing needs during the pandemic. 16:01 Supplemental benefits as a decision-making factor in enrollees’ Medicare Advantage plan selection. 16:28 “The decisions made during this time with how to increase benefits or how to address the issues going on with your membership will have a really great impact on [your] AEP [annual enrollment period].” 18:12 “I think that there’s a real lack of understanding … around what issues are impacting their actual membership … but really understanding the demographics and the social determinants of health that are impacting your local landscape.” 19:30 “Health care’s not always related to in-office doctor visits.” 19:40 “I really do think that CMS is headed … to understanding that federal dollars for the Medicare program should not just be spent on doctor’s visits or screenings.” 21:10 “I think that there’s been a real shift in … what we understand now and also what we’re able to predict.” 23:24 Where Medicare Advantage plans fall in addressing population health management, working with hospital organizations, and social determinants of health. 24:24 Betsy’s advice for providers dealing with MA plans. 24:46 “I … think that this is … a missed opportunity [for] provider and plan partnership in a lot of ways.” 26:07 “Really understanding that the market has shifted and the way the beneficiaries enroll this year is going to be very different than it ever has been before.” 29:25 “One thing that shouldn’t be overlooked is that we really have an opportunity to dig into the data.” You can learn more at rebellisgroup.com. Check out our latest #healthcarepodcast with @betsyseals of @GroupRebellis as she discusses #medicareadvantageplans. #healthcare #podcast #digitalhealth #MAplans What is a Medicare Advantage plan? @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “How is risk adjustment functioning?” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “We all want to know why members are leaving. Well, they’re telling you!” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “Now, it’s not just ‘Is your doctor in the network?’ It’s ‘Does your plan also offer telehealth?’” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “The decisions made during this time with how to increase benefits or how to address the issues going on with your membership will have a really great impact on [your] AEP [annual enrollment period].” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “I really do think that CMS is headed … to understanding that federal dollars for the Medicare program should not just be spent on doctor’s visits or screenings.” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “I … think that this is … a missed opportunity [for] provider and plan partnership in a lot of ways.” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans

In this health care podcast, I talk with Karl Bilimoria, MD. Dr. Bilimoria is a surgical oncologist and a VP of quality over at Northwestern Medicine. Plus, he is also a John B. Murphy professor of surgery. The second I heard that Dr. Bilimoria and his colleagues had worked on an initiative to “rate the raters” of hospital and physician quality, I reached out to get him on the show. I had just had about four conversations with various people about the difficulties of judging quality. And I had also had a confounding personal experience visiting a patient at a hospital judged a top hospital by a well-known national rating scale. And this “top” hospital had some readily apparent issues, and I am no expert. That got me wondering about the validity of some of these quality raters. Given the importance and the need for health care quality transparency, Dr. Bilimoria and his colleagues set out to fill this gap by undertaking a (as mentioned) Rating the Raters process to evaluate and compare probably the major publicly reported hospital quality rating systems in the United States. These include the CMS (Centers for Medicare and Medicaid) Hospital Compare Overall Star Ratings, Healthgrades Top Hospitals, Leapfrog Safety Grade and Top Hospitals, and the U.S. News & World Report Best Hospitals.  Interestingly, that “top” hospital I was in was scored a top hospital by one of the lowest-rated raters. You can learn more at the New England Journal of Medicine Web site, thesecondtrial.org, and the NEJM Catalyst Web site.  Karl Bilimoria, MD, is a surgical oncologist and a health services, quality improvement, and health policy researcher at Northwestern University’s Feinberg School of Medicine. He is the vice president for quality for the Northwestern Medicine system. He is also the vice chair for quality in the Department of Surgery and the John B. Murphy professor of surgery. His clinical practice is focused on melanoma and sarcoma. Dr. Bilimoria is the director of the Surgical Outcomes and Quality Improvement Center of Northwestern University (SOQIC), a center of 50 faculty and staff focused on national, regional, and local quality improvement research and practical initiatives. He is also the director of the 56-hospital Illinois Surgical Quality Improvement Collaborative (ISQIC). Dr. Bilimoria has published more than 350 scientific articles, including numerous publications in JAMA and the New England Journal of Medicine. His research is funded by the National Institutes of Health, the Agency for Healthcare Research and Quality, Health Care Services Corporation, and numerous others. He was recently listed by Becker’s as one of the “Top 50 Experts Leading the Field of Patient Safety” in the United States. 02:06 The impetus for Dr. Bilimoria deciding to rate the raters. 03:38 How high the stakes are when considering these ratings. 05:01 Breadth vs depth when choosing how and what to measure among the rating systems. 05:38 What rating systems the Rate the Raters looked at and why. 06:11 Who got the best scores as a rating system and who got the worst? 06:58 Dr. Bilimoria and the Rate the Raters’ qualifications on rating these rating systems. 07:35 The methodology and criteria that the Rate the Raters came up with to evaluate these rating systems. 08:01 The six criteria that the Rate the Raters system uses to evaluate rating systems. 08:39 “At every step, we included the rating systems.” 09:14 The intent behind Rate the Raters. 09:55 Why having grades is a positive for the health care consumer. 10:41 What conflicts of interest might be of concern among these rating systems? 12:22 “Notable notes” for these rating systems, and what each rating system incorporates or doesn’t incorporate, and how these things affected their rating. 18:22 Creating a gold standard and finding ways to move the field forward. 22:05 Getting to better data in the short term and the long term by doing meaningful audits. 24:09 Individual ratings vs institutional ratings and where these intersect. 26:27 Dr. Bilimoria’s advice to employers and how to pick a rating system. 27:45 “These rating systems should be interpreted very cautiously, even the best of them.” 28:03 “Triangulate the data.” 30:07 What Dr. Bilimoria and Rate the Raters are currently working on. You can learn more at the New England Journal of Medicine Web site, thesecondtrial.org, and the NEJM Catalyst Web site.  Check out our newest #healthcarepodcast with @kbilimoria. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata What started #RatetheRaters? @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata When considering #healthratings, how high are the stakes? @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata Breadth vs depth in #healthrating systems. @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata What #healthrating systems did #RatetheRaters look at and why? @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata How did each #healthrating system score with #RatetheRaters? @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata What are the #RatetheRaters qualifications in assessing these #healthrating systems? @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata What evaluating criteria do #RatetheRaters use? @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata The six criteria to evaluating #healthrating systems. @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata “At every step, we included the rating systems.” @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata What’s the intent behind #RatetheRaters? @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata Are grades a positive for #healthconsumers? @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata Creating a gold standard. @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata Individual ratings vs institutional ratings. @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata “These rating systems should be interpreted very cautiously, even the best of them.” @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata “Triangulate the data.” @kbilimoria discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthoutcomes #healthcarequality #qualitymetrics #healthdata

  Let’s Talk Healthcare and Insurance for a Second! This episode is dedicated to Vicky Ann Luke Dr. Josh Luke – Episode 707 Healthcare has become unaffordable for the average American family, entrepreneur and small business owner. The key to reducing healthcare costs is to become an Engaged Healthcare Consumer. Josh explains- CMS- Centers for Medicare […] The post Dr. Josh Luke- Rules-Regs & Dregs! appeared first on Boomers Rock.

Patients, families, caregivers are generating data outside of the health care setting. They are tracking exercise, symptoms, blood pressure. And they’re coming in for their appointments bearing stacks of printouts or their username and password on a little piece of paper and asking their clinicians to log in to their accounts and check out the goings on. Clinicians, meanwhile, struggle to understand how to bring these data elements into provider environments so that the data can improve engagement and can improve care and outcomes. How can all this data be used to help patients better self-manage? In this health care podcast, I speak with Vicky Tiase, a nurse informaticist and director of informatics strategy over at NewYork-Presbyterian Hospital. We talk about the opportunities to use patient-collected data, but mostly we discuss the barriers and how to overcome them. We also consider the flip side to this: a new CMS (Centers for Medicare and Medicaid Services) rule that mandates that providers must make provider-collected data available back to patients in a form of the patient’s choosing. How does that fit into this picture? It’s interesting to observe that there’s at least two schools of thought emerging relative to which apps patients use. Or maybe a better way to put it: It’s less about two schools of thought and maybe more like two phases to a larger goal. One might come before the other. One school of thought concludes that provider organizations should prescribe apps, since it makes it easier on the back end to assimilate the data into clinical workflows and also hearkening back to the patriarchal origins of medicine—Doctor knows best and should tell the patient what to do. The other school of thought concludes that patients should be able to pick their own apps that appeal to them. The place that these two priorities merge is if apps are part of a trusted framework so that no one winds up with anything developed by Russian hackers, but yet the choice can still be left up to patients but within, like I said, this trusted framework. Vicky will be speaking at the Digital Medicine Conference sponsored by NODE.Health. That event is coming up on December 9 in New York City. NODE.Health, by the way, stands for the Network of Digital Evidence. Look it up on the Web if you have questions. I will be at the Digital Health Conference. If you’re going to be there, too, let me know! You can learn more by connecting with Vicky on Twitter at @vtiase, or join her at the NODE.Health Digital Medicine Conference on December 9, 2019.  Victoria (Vicky) Tiase, MSN, RN, is the director of research science at NewYork-Presbyterian (NYP) Hospital. She has over 13 years of experience of giving clinical input to technology projects in all areas, especially regarding the implementation of the NYP electronic medical record. Vicky is responsible for supporting a range of clinical information technology projects related to patient engagement, alarm management, and care coordination. She was the nursing lead for the design, implementation, and rollout of an institution-developed personal health record (PHR), myNYP.org. She is passionate about finding data-driven, information technology (IT) solutions for increased patient and provider engagement in health care and leads research efforts to ensure the capture and presentation of data for the use and benefit of clinicians. Vicky serves on the steering committee for the Alliance for Nursing Informatics (ANI) and recently completed a fellowship in the ANI Emerging Leaders Program assessing nurse readiness to use health IT tools for patient engagement. She completed her master’s in nursing informatics at Columbia University and is currently pursuing a PhD from the University of Utah with a focus on the integration of patient-generated health data into clinical workflows.  03:04 What patients are looking for from their provider when they collect their own data. 03:29 The two categories of patients gathering data. 05:27 Patients looking to participate. 06:34 Encouraging a continuation of data collection while learning to use that data. 07:00 The importance of needing a feedback loop in patient data collection. 08:22 Why clinicians are confused about patient data and patient data barriers. 09:59 “It comes down to the data.” 11:00 The pieces of patient data that clinicians need to explore. 11:38 Understanding decision needs and understanding which data are going to be most valuable to clinicians. 12:26 Contending with the saturation of health data collection apps. 13:53 Empowering patients to use the app of their choosing, while vetting these apps. 15:13 What the ideal patient data collection looks like. 16:54 “Seamless data sharing.” 18:04 Are different patient data solutions necessary for different cohorts of care? 18:55 EP157 with Dr. Ethan Basch. 20:27 “It’s not just data that we’re looking at, but … data are translated into information, and from information … into knowledge.” 25:01 Vicky’s advice: Understand your organizational policies. 28:52 The best solutions for patients collecting and wanting to share their data from a variety of apps. 30:01 The need to think about consumer-directed exchange. 30:49 What Vicky’s looking forward to at the NODE.Health conference event. You can learn more by connecting with Vicky on Twitter at @vtiase, or join her at the NODE.Health Digital Medicine Conference on December 9, 2019.  Check out our newest #healthcarepodcast with @vtiase of @nyphospital and @DigMedEvidence. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 What are #patients looking for from #providers when they collect #data? @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 What are the two categories of #patients collecting #data? @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 How #patients are looking to participate when gathering their own #data. @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 Learning to use the #data #patients collect. @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 How important is a feedback loop in #patient #datacollection? @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 Why are #clinicians confused about #patient #data? @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 What are the barriers to #patient #datacollection? @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 “It comes down to the #data.” @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 What parts of #patient #data should #clinicians be exploring? @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 Understanding decision needs. @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 Navigating the oversaturation of #health #data #apps on the market. @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 #empoweringpatients and encouraging their #datacollection. @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 What does the ideal #patient #datacollection look like? @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 “Seamless #datasharing.” @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19 Thinking about consumer-directed exchange. @vtiase of @nyphospital and @DigMedEvidence discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthdata #healthtech #patientdata #DMC19

Listen in for a conversation about health care trends, patient outcomes, and the evolving role of speech language pathologists in skilled nursing facilities. We’ll hear from ASHA’s director of Health Care Services and a panel of SLPs in leadership roles at rehab companies. We’ll discuss both challenges and opportunities they see in this time of change.   Acronym Guide: PDPM - Patient Driven Payment Model; SNF - Skilled Nursing Facility; CMS - Centers for Medicare and Medicaid Services; RUG-IV - Resource Utilization Group; MDS - Minimum Data Set

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves discuss a procedure called minimally invasive lumbar decompression or MILD. What exactly is MILD? Well, it's a way to create more space in the spine with utilizing small entry ports- which means no large incisions, less recovery time after the procedure and decreased risk for the patient. Listen as the docs discuss the two main studies that brought the MILD procedure back into relevance (and coverage by CMS - Centers for Medicaid and Medicare Services) References: Benyamin RM, Staats PS.MiDAS ENCORE: Randomized Controlled Study Design and Protocol.Pain Physician. 2015 Jul-Aug;18(4):307-16. Mekhail, Nagy, et al. (2012), Functional and Patient-Reported Outcomes in Symptomatic Lumbar Spinal Stenosis Following Percutaneous Decompression. Pain Practice, 12(6): 417-425. Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people. This podcast is for information and educational purposes only, it is not meant to be medical advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.

In an article written by Jason Kane for PBS News Hour, he states that the United States spends $8,233 per person on health care annually. http://www.pbs.org/newshour/rundown/health-costs-how-the-us-compares-with-other-countries/“According to the CMS (Centers for Medicare/Medicaid Spending), the average American spent $9,596 on healthcare last year, up significantly from $7,700 in 2007. Healthcare spending per person is expected to surpass $10,000 in 2016 and then march steadily higher to $14,944 in 2023.” http://www.fool.com/investing/general/2015/03/15/the-average-american-spends-this-much-on-healthcar.aspxCompare this with American incomes: the Federal Reserve Economic Data website states that in 2015, median personal income in America was observed at $30,240 and mean personal income was at $44,510.Median Income: https://fred.stlouisfed.org/series/MEPAINUSA672NMean Income: https://fred.stlouisfed.org/series/MAPAINUSA672NAffordable Care ActACA Pros: http://www.aarp.org/health/health-insurance/info-08-2013/affordable-care-act-health-benefits.htmlBenefits of ACA: http://www.vox.com/the-big-idea/2016/11/23/13719388/obamacare-health-insurance-repeal-trumpACA CONS: Taxation as a punishment for not signing up, rising costs of insurance premiums, high deductibles from $10k – $50k.ACA for CA state in 2017: Rising costs of insurance premiums and medical insurance in CA state: “But as Californians receive their premium rates for next year, some — including those who make too much to qualify for those government subsidies — are learning their hikes will be far higher than the average statewide increase of 13.2% announced by the state insurance exchange in July.” http://www.latimes.com/business/la-fi-covered-california-premiums-20161026-story.htmlACA for WA State 2017: Rising costs of insurance premiums and medical insurance in WA state: http://www.seattletimes.com/seattle-news/health/health-insurance-premiums-rise-here-in-state-but-not-as-high-as-elsewhere/Professor Peter C Gøtzsche graduated as a Master of Science in biology and chemistry in 1974 and as a physician in 1984. He is a specialist in internal medicine; worked with clinical trials and regulatory affairs in the drug industry 1975-1983, and at hospitals in Copenhagen 1984-95. With about 80 others, he helped start The Cochrane Collaboration in 1993 with the founder, Sir Iain Chalmers, and established The Nordic Cochrane Centre the same year. He became professor of Clinical Research Design and Analysis in 2010 at the University of Copenhagen.Peter has published more than 70 papers in “the big five” (BMJ, Lancet, JAMA, Ann Intern Med and N Engl J Med) and his scientific works have been cited over 15,000 times. Peter has also authored 3 other books.“Deadly Medicines and Organised Crime” written in 2013 by Professor Peter C Gøtzsche.“Mammography: Truth, Lies and Controversy” by Peter C Gøtzsche.“And screening has not reduced the number of advanced cancers, 3 which is a prerequisite for screening to work. In Denmark, the overdiagnosis was 33% after 17 years with screening, 4 in good agreement with the 30% estimate from the trials.”http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)61216-1.pdfDr. Atul Gawande's TED Talk from March 2012:https://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine?language=enThe Atlantic, November 29th, 2016. In the article it describes Cuba's healthcare system, which costs 1/10th of what America's costs and achieves higher life expectancy as America. http://www.theatlantic.com/health/archive/2016/11/cuba-health/508859/Open-ended question: Should we have to continue to pay for true healthcare out of our pockets and savings? Is healthcare a human right?Other Resources:NPR – “How do pharmaceutical companies establish drug prices”http://www.npr.org/2016/02/05/465748256/how-do-pharmaceutical-companies-establish-drug-pricesOnly 13% of all orthodox medicine has been proven to have benefit AND another 23% is shown to have likely benefit:http://www.dcscience.net/garrow-evidence-bmj.pdfStats on people with Diabetes in USA — CDC says 30 million diagnosed in 2017:https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdfThis is equal to just over the population of Texas and around 85% of the population of Canada.Prices getting spikedhttp://www.pbs.org/newshour/rundown/whats-behind-skyrocketing-insulin-prices/http://www.wsj.com/articles/mylan-faces-scrutiny-over-epipen-price-increases-1472074823http://www.businessinsider.com/epipen-cost-increase-healthcare-insurance-2016-8Life Expectancy Drops in the USA for unknown reasons according to NPR:http://www.npr.org/sections/health-shots/2016/12/08/504667607/life-expectancy-in-u-s-drops-for-first-time-in-decades-report-findsGeneric Medications FAQ from the FDA Link:https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/understandinggenericdrugs/ucm167991.htm

In this episode of Eldercare Illuminated, host Lenore Tracey and elder law attorney Cathy Sikorski shed light on an enduring misunderstanding about Medicare coverage for skilled services.For years, Medicare recipients have been denied coverage for services, such as skilled nursing, physical therapy, and occupational therapy, based on the notion that they have plateaued or there is a lack of restoration potential. For example, patients were told (and are still being told) that Medicare would no longer pay for physical therapy because there was no potential for improvement in their condition. Perpetuated for years, this notion has resulted in patients not getting needed services to which they are entitled and from which they can benefit.Cathy shares the facts and the strategies you need to dispel this myth and advocate effectively for your loved one. Listen and learn. Then check out additional information from the Centers for Medicare and Medicaid Services (and print materials to bring with you) so you have all the information in hand if you need to get your loved one’s providers up to speed.1. Updated Publication from CMS (Centers for Medicare and Medicaid Services), because federal court found that 'virtually no effort' was made to promote the Jimmo vs. Sebelius settlement. https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html 2. Frequently Asked Questions associated with the above publication: https://www.cms.gov/Center/Special-Topic/Jimmo-Settlement/FAQs.htmlCaregivers, you make such a difference in your loved one’s lives!About Our Guest:Cathy Sikorski has been a caregiver for the last 25 years for seven different family members and friends. A published author and humorist, Sikorski is also a practicing elder law attorney. Her legal expertise and sense of humor have made her a sought-after speaker where she tackles the legal issues that affect those who will one day be or need a caregiver (which is everyone).Cathy’s first book is a humorous memoir Showering with Nana: Confessions of a Serial (killer) Caregiver. That was followed by Who Moved My Teeth? - a humorous and informative book with practical and legal tips for caregivers and baby boomers. Cathy maintains an active blog “You just have to Laugh…where Caregiving is Comedy…”.

In this episode of Eldercare Illuminated, host Lenore Tracey and elder law attorney Cathy Sikorski shed light on an enduring misunderstanding about Medicare coverage for skilled services.For years, Medicare recipients have been denied coverage for services, such as skilled nursing, physical therapy, and occupational therapy, based on the notion that they have plateaued or there is a lack of restoration potential. For example, patients were told (and are still being told) that Medicare would no longer pay for physical therapy because there was no potential for improvement in their condition. Perpetuated for years, this notion has resulted in patients not getting needed services to which they are entitled and from which they can benefit.Cathy shares the facts and the strategies you need to dispel this myth and advocate effectively for your loved one. Listen and learn. Then check out additional information from the Centers for Medicare and Medicaid Services (and print materials to bring with you) so you have all the information in hand if you need to get your loved one’s providers up to speed.1. Updated Publication from CMS (Centers for Medicare and Medicaid Services), because federal court found that 'virtually no effort' was made to promote the Jimmo vs. Sebelius settlement. https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html 2. Frequently Asked Questions associated with the above publication: https://www.cms.gov/Center/Special-Topic/Jimmo-Settlement/FAQs.htmlCaregivers, you make such a difference in your loved one’s lives!About Our Guest:Cathy Sikorski has been a caregiver for the last 25 years for seven different family members and friends. A published author and humorist, Sikorski is also a practicing elder law attorney. Her legal expertise and sense of humor have made her a sought-after speaker where she tackles the legal issues that affect those who will one day be or need a caregiver (which is everyone).Cathy’s first book is a humorous memoir Showering with Nana: Confessions of a Serial (killer) Caregiver. That was followed by Who Moved My Teeth? - a humorous and informative book with practical and legal tips for caregivers and baby boomers. Cathy maintains an active blog “You just have to Laugh…where Caregiving is Comedy…”.

In part one, show host Michael Koriwchak, M.D. is about to share bold news about CMS (Centers for Medicare and Medicaid Services). In part two, Koriwchak reruns the best segments from a show two weeks ago featuring D4PCF President Lee Gross and his report on the legislative trojan horse for DPC.

Today’s show is something that most of us misunderstand, we don’t know how to talk to our customers about it, and we simply do not know what the right information is and where to go find it. We are talking about the L word today; Legionella. We are going to get to the bottom of what Legionella is, what we need to know about it, how we explain it to our customers, and how we get everybody working together towards a common goal. Episode 9: Show Notes We welcome Dr. Janet E. Stout, she is the president and director of Special Pathogens Laboratory, and research associate professor at the University of Pittsburgh Swanson School of Engineering in the Department of Civil and Environmental Engineering. A clinical and environmental microbiologist, Dr. Stout is recognized worldwide for more than 30 years of pioneering research in Legionella. Her expertise includes disinfection and control strategies for the prevention of Legionnaires’ disease and other waterborne pathogens. She is credited as the first to demonstrate the link between Legionnaires’ disease and the presence of Legionella in hospital water systems. Key Points From This Episode: Janet shares with us about who she is and what she does. Learn how Legionella cannot be treated by all kinds of antibiotics, only certain selected ones. Find out what the signs and symptoms are of Legionnaires disease. Understand what a water treater can do to prevent Legionella. Learn what building owners need to understand about cooling towers and utility water systems and the questions we need to be asking these owners. Hear how New York is the first to have a law that requires building owners to adhere to specific requirements. Janet tells us where to get information on the guidelines and standards for Legionella. Find out what the Ashrae 188 document is all about, and how it is used. Understand what the different serogroups for Legionella are. Hear how there is a lot of freedom in the standard 188 for you to make decisions. Understand why Ashrae 188 in New York only deals with the water in cooling towers. Learn more about the Centre for Medical and Medicaid Services Document on Ashrae 188. Find out why you need to test for Legionella and what systems you should be testing. Understand how to test for Legionella in the facility and how it benefits. Hear how only about 30-50% of cooling towers are positive for Legionella. Janet tells us what to do if your test for Legionella in the water comes back positive. Learn how decisions made need to be evidence-based. Understand the procedure on the collection part of the Legionella test. Learn about the ELITE program developed by the CDC. Find out what to look for in the laboratory you choose to do your testing. Learn more about what dual biocides are and how they should be used. Understand why it’s important to have a water management program. Hear what’s an acceptable free chlorine and what to test for when you’re testing chlorine. Find out why you need to take negligence off the table. Janet tells us what she sees around the topic of Legionella that needs to stop. And much more! Tweetables: “The symptoms of legionnaires disease is no different than the symptoms of other forms of pneumonia.” — @specialpathogen [0:08:00.0] “I always try to have a little lawyer on my shoulder when I am advising our clients on Legionella management.” — @specialpathogen [0:32:07.0] Links Mentioned in Today’s Episode: Dr. Janet E Stout — http://www.specialpathogenslab.com/ Email Janet — jstout@pathogenslab.coom Janet on Twitter — https://twitter.com/specialpathogen Ashrae Website — https://www.ashrae.org/ CDC Website — https://www.cdc.gov/ US Environmental Protection Agency — https://www.epa.gov/ Legionella — http://legionella.org/ The treasure trove of resources she mentioned — http://www.specialpathogenslab.com/resources-1.php CDC Legionella Toolkit — https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html Here is some more information on  CDC, AWT, ASHE and CMS (Centers for Medicare & Medicaid Services) concerning Legionella, ASHRAE 188 and water management plans. The CDC just released “version 2” of their Toolkit & VitalSigns publications that were first released in June of 2016 – the message and advocacy is still very strong and clear that building owners have an ASHRAE 188 compliant “Water Management Plan” (or better) – w/this year’s focus and data particularly on Healthcare Facilities! The VitalSigns document title is: Legionnaires Disease – A Problem for Health Care Facilities!  Here is a copy of CDC's VitalSigns, MMWR and a Link to the CDC Toolkit. AWT quickly responded to the CDC releases w/their own press release of the CDC – note that the CDC (now) specifically recommends contacting a “water treatment professional” for water management plan development – and not a “plumber”.   ASHE also responded w/acknowledgement of the CDC focus on Legionella management in healthcare facilities – see ASHE News. Maybe the most significant event is the CMS update memorandum (effective immediately 6/2/17) that has very specific expectations/requirements for health care facilities receiving CMS funds to have an 188 equivalent water management plan AND “environmental testing for pathogens” (Legionella).

Each year CMS (Centers for Medicare and Medicaid) measures Medicare Advantage Plans (Part C) and Part D Prescription Drug The overall Star Rating of a plan provides a way to help beneficiaries compare the performance of several plans. The overall Star Rating of a plan provides a way to help beneficiaries compare the performance of several plans. For more information on Medicare's Star Ratings and how they affect you, visit https://blog.trustedseniorspecialists.com/star-ratings-what-are-they-and-how-do-they-affect-me/ For immediate Medicare questions or concerns, feel free to give our licensed agents a call at 1-855-474-6234 TTY 711 or set up an appointment https://www.trustedseniorspecialists.com/schedule-your-appointment

Welcome, Medicare Nation! Today’s topic is Diabetes Prevention, based on the expansion of a pilot program instituted by the CMS (Centers for Medicare/ Medicaid Services). I’ll be explaining the program’s components and the results. Join me! What you’ll hear in this episode: Statistics about diabetes: There are currently more than 30 million Americans with Type 2 diabetes. There are TWO deaths every FIVE minutes from diabetes! There are 86 million Americans at a high risk of developing diabetes. One out of three adults have “pre-diabetes,” which means they have higher than normal (normal is

Medicare Secondary Payer, better known as MSP, took center stage in 2014 when it came to impacting the structured settlement industry. Ringler Radio host, Larry Cohen along with colleague, Tom Blackwell, Vice President and Program Director of Ringler Medicare Solutions, Inc. (RMS), talk about the changes in CMS(Centers for Medicare and Medicaid Services) submissions, liability, educating clients and what we can expect in 2015.

Medicare Secondary Payer, better known as MSP, took center stage in 2014 when it came to impacting the structured settlement industry. Ringler Radio host, Larry Cohen along with colleague, Tom Blackwell, Vice President and Program Director of Ringler Medicare Solutions, Inc. (RMS), talk about the changes in CMS(Centers for Medicare and Medicaid Services) submissions, liability, educating clients and what we can expect in 2015.