Justin Ley

Very interesting article. It compares hospital and health plan consolidation in specific markets. Indiana is a market that is deemed a high cost market (7th highest in nation for hospital costs) because of hospital consolidation per studies, yet when you look at the market, plans have more leverage as the top 3 represent 91% of the large group market. A few thoughts: 1) you can look at number of hospitals, but it would be better to compare commercial spend for these systems as I would imagine a lot higher than the counts indicate. Some hospitals may have a higher proportion of governmental business and that needs to be considered. 2) Based on plan leverage, one would think plans would say no to continued commercial price increases. It's important though that employers support plans in these discussions. I have seen many times over the years that employers want access above everything else, which means the plan has little leverage with the hospital to take hard line stands or risk losing large national employers who will just switch to another plan creating a vicious cycle of continued cost increases. 3) Under this environment, there is little incentive to move to VBC like arrangements vs. fee for service. 7. For example, in Indiana, the systems with the largest share of total hospitals are St. Louis-based Ascension (13.9%), Indianapolis-based IU Health (11.3%), Mishawaka-based Franciscan Health (8.7%) and Franklin, Tenn.-based Community Health Systems (8.7%). These four systems own 42.6% of all the hospitals in Indiana combined 8. On the other hand, the three largest payers in Indiana — Elevance Health (68.9%), UnitedHealth Group (17.1%) and Physicians Health Plan of Northern Indiana (5.3%) — represent 91.2% of all privately insured patients with insurance from the large-group market.  

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How Much Variation Should There Be in the Pricing of a CT Scan, from the *Same​* Provider in Michigan? Here's a real life example of from one of finHealth's clients. The names have been changed to protect the innocent (until proven guilty).   This is the actual distribution of CT scan of the abdomen and pelvis with contrast in the Michigan region – all from the same provider. Typical cost at this facility is $400, but here we also see this same provider exceeding $2,700 on multiple occasions. Why does the contract allow much significant pricing variation for the same service from the same provider? Is your BUCA contract allowing for this? Do you know? 𝑯𝒐𝒘 𝒘𝒐𝒖𝒍𝒅 𝒚𝒐𝒖 𝒌𝒏𝒐𝒘? #healthcare #cost #fiduciary #howwouldyouknow

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⏰ A Chicago-based leader in Fractional Marketing for healthcare startups shared some eye-opening insights recently. What used to take 30-45 days to get to a signed contract is now stretching to 90-120 days. What has changed? • Executive decision-makers are drowning in tasks, leaving them scrambling to find the perfect marketing match to propel their growth. • Analysis paralysis: Hire a junior full-time employee, enlist the help of an agency, or consult with a seasoned expert. Too many choices, too little time. • Boards are stepping up their game, getting involved in decisions, and even bringing marketing teams to the table. • And let’s not forget the ever-evolving healthcare landscape, where business strategies must adapt or risk being left behind. You need a marketing partner who not only understands these shifts but anticipates them, guiding your company to success every step of the way. Are you going to wait 30 days . . . or 120 days to find that thought partner who can help your company grow? 👉🏼 Let me help you tailor your marketing approach for your growing healthcare startup. Give me a shout if you’re ready to get started! >> https://lnkd.in/gxjxYy_x

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HSG Advisors Dashboard is changing the game for healthcare leaders. It provides information they've never had access to and makes it actionable so leaders can make informed decisions about competitor dynamics, service line growth, access point strategies, and much more! Ready to see a demo? Set up a time on my calendar. https://lnkd.in/gAvyUkny #healthcareconsulting #healthcareleaders #hospital #hsgdashboard #healthsystem #claimsdataanalytics

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I waited as long as could before commented on the rash of departures from Big Retailers shutting down their various Primary Care investments. This is unfortunate as we need as much investment, innovation, and incremental experimentation to solve the very challenging problems of cost, quality, access, and outcomes impacting the very foundation of our nations health. However, when Primary Care is viewed as a secondary means to some other primary end, it’s going to be challenging to make it work. It’s a people business, with staffing being the largest component, which requires systems, processes, and technology to be smartly harnessed together–with a Service Design mentality–to ensure that each part contributes to a larger, systematic whole. Primary Care is best served “warm”, in the context of a trusted relationship that has been built over time. But critically, Primary Care needs a care model and service experience that also fits into a rational, sustainable, and viable business mode that can endure over time and varied economic circumstances. I would argue that this is one of the most critical, and probably most overlooked components of so many Primary Care initiatives–ensuring that there’s a sustainable business model.  The business model must embed the concept of Advanced Primary Care being paid for by redirecting as needed (referral management) and rightsizing care (care management / focus on health and wellbeing) which by definition means reallocating how we spend the dollars. I always revert back to the landmark study on Primary Care, the National Academy of Engineering, Science, and Medicine (NAS) on Implementing High Quality Primary Care (“IHQPC”), which not only spoke to the chronic underinvestment in Primary Care and the serious economic and health implications which result; but more importantly, identified a way to implement the changes that are required to find a new path forward. Primary Care’s role is most definitely not to be the well-intentioned but loss-leading road to hell(th). One thing is for certain, the solution to the Primary Care challenges in the US will not be found on Aisle 3.  

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Here’s your recap of last week’s health IT news 🗞️ Notable partnerships 🤝 • Kaiser Permanente is partnering with Innovaccer to incorporate their population health and AI platform        • MUSC Health adopted Andor Health’s ThinkAndor in its ED to reduce wait times and “leaving without being seen” rates.      • Upperline Health is partnering with Navina to improve clinical workflows and improve the accuracy of patient histories.      • Intermountain Health deployed Nuance Communications DAX Copilot, an AI ambient scribe solution.      • PA Clinical Network is partnering with Guidehealth  to improve outcomes and care quality while improving physician efficiency. Product updates 👩🏼‍💻 • Klara released a new patient intake product for athenahealth users.    • Baton Health released Universal Primary Source, giving users access to hundreds of primary source databases for credentialing.    • InsightRX released InsightRX Apollo, an analytics platform that provides insights on clinical performance.    • Trovo Health launched with a $15 million seed round, offering specialty-specific AI combined with clinical experts to help practices add to their capabilities.    • Quest Diagnostics acquired PathAI’s diagnostic laboratory business (PathAI Diagnostics) to improve Quest’s oncology services.    • GenHealth.ai launched its Automated Prior Authorization platform.    • Veradigm® is partnering with MedEvolve, Inc. to make its suite of products available to Veradigm users.    • CLEW announced availability of a newly FDA-approved patient surveillance platform. Posts we enjoyed 👏 • Eric Topol, MD shared a compelling piece reviewing the state of research on AI in medicine. In short, we’re seeing our first early evidence that AI can reduce mortality as a research endpoint, but large language models are not yet the panacea we’ve been promised. (https://lnkd.in/e6hK-4mr)    • Nikhil Krishnan of Out-Of-Pocket shared a deep dive on Stedi, which converts X12 EDI into JSON-based APIs for healthcare tech developers. (https://lnkd.in/eqS9V5zW) --- Want to stay in the loop? Sign up for the Elion Briefing to get all of the latest healthcare tech news delivered to your inbox 📬 👉 https://bit.ly/49z6AUW

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#Startups - Take note! The blog post from Michael A. Greeley of Flare Capital Partners does an excellent job of highlighting key practices in #scaling a #healthcare startup effectively. Check it out and take what Michael says to heart - or in this case - to stomach. #startupsuccess #innovation #healthcareonLinkedin https://lnkd.in/e7wr2Gry

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Quarterly Q&As are out! These are mini refreshers or clarifiers for everyone in the home health industry! Question 1 is GOLD for businesses like ours. Question 1: A third-party external auditor consistently states that our OASIS functional status items are “underscored” and recommends changing the responses to the OASIS items. Is the assessing clinician required to accept the auditor’s recommendations? Answer 1: While a home health agency may use third party external auditors to review OASIS coding and make recommendations, the assessing clinician is responsible for determining OASIS coding based on their assessment. We often get clinicians who don’t understand the reasoning or rationale. The longer or more detailed it is— consider it unread. That is NOT compliance. Truth be told, most of the clinicians are reviewing these changes in the field or at home after a 10 hour home health shift. Their brains are at capacity for receiving more info. I should know, I was one of those clinicians. Family time is now met with 6 inch long “yellow sticky notes”. That’s why most of these clinicians have my personal email and phone number. I thrive on educating and so I always encourage them to “call me with questions”. You’ll usually find me at 9pm explaining why M2020 is likely marked as 3 if M1860 is stating patient requires assistance or supervision of another person at ALL times during ambulation. What’s your consultant team doing to bridge the gap between making clinicians aware of changes made and EDUCATING on changes being made? Contact me for more info on how C&C Strategic Consulting can assist your agency!

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Bigger isn't always better in healthcare. Just look at the graphic below. Some of the largest health systems in the country are underperforming. They've entered (or operate in) bad markets, hold bloated cost structures, and struggle to hold leverage against payors. As it turns out, and as I'm often reminded, market performance matters. It doesn't matter that you're just big and can absorb a vast swath of overhead. As a health system, the way you throw your weight around in markets is more important than ever. This is the key concept of density and having the right assets in the right markets. CVS, HCA, Tenet, and others all have mentioned the importance of market density in 2024. Density - and being dense in attractive markets - is primarily what separates -3.9% from 10%+ operating margins. I should have paid attention in physics!! PS: if you like graphics and analysis like this, subscribe to my newsletter Hospitalogy here with 34k+ others: https://lnkd.in/gniNmHvz

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Thank you How to HealthTech for having us on your show to talk denials. This conversation is rich with information on exactly the problem of denials in our current state! https://lnkd.in/gDa7WQtM with Wael Khouli, MD, MBA

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At TPN.health we are a mission-first company. Our goal is to improve patient outcomes.That means, every decision, every piece of code, and every product we launch is rooted in answering these questions: How does this serve our mission? How does what we're building improve behavioral health outcomes? How can we positively impact and create change in our industry?

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Here’s your recap of last week’s health IT news 🗞️ Notable partnerships 🤝 Premier Inc.’s hospital system network will now have access to pre-negotiated pricing & terms when implementing Suki. Baptist Health is expanding its usage of Caregility's intelligent bedside telehealth devices in support of additional virtual care programs. St. Luke's University Health Network is leveraging Best Buy Health’s Current Health remote monitoring platform to continue to treat CHF patients after discharge. UChicago Medicine is utilizing Abridge and studying its impact on clinician wellness, retention, and patient outcomes. NYC Health + Hospitals is expediting its transition to Experian Health following the Change Healthcare ransomware attack in February. The MetroHealth System (Cleveland, OH) — one of two health systems responsible for founding Ovatient — went live with virtual care services and prescription delivery. Product updates 👩🏼‍💻 In-House Health, an AI scheduling and workforce management platform for nursing teams, launched following a $4 million seed funding round. Rad AI announced a $50M Series B round. NeuroFlow released a new care pathway for perinatal and postpartum care. Rimidi + Senseonics, Incorporated partnered on a remote patient monitoring program for patients with diabetes. WellSky released a new value-based insights analytics solution for hospice agencies. Vivalink released its ambulatory ECG monitoring solution. BrightInsight embedded a Google Gemini-powered AI bot within its disease management solution. Stel Life is leveraging Xealth's EHR integration solution to facilitate faster workflows and improved security. Posts we enjoyed 👏 The team at Oscar Health shared part one of a fascinating series on how they’re using large language models to find answers to questions in often cumbersome and unstructured medical records. https://lnkd.in/e2_NCyy4 Brendan Keeler (aka Health API Guy) shared a deep dive on the new CMS-9115, the CMS Interoperability and Patient Access Rule. https://lnkd.in/eumG9eUT We enjoyed reading through Graham Walker, MD's LinkedIn post (and comments section) reacting to the Federation of State Medical Boards’ guidance on physicians’ responsibility and liability when it comes to the use of AI in clinical decision support. https://lnkd.in/en-6GmDP --- Want to stay in the loop? Sign up for the Elion Briefing to get all of the latest healthcare tech news delivered to your inbox 📬 👉 https://bit.ly/49z6AUW

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Excellent article by Nona Tepper at Modern Healthcare explaining how Medicare Advantage #starratings are calculated and how they impact member recruitment. While they're not perfect, Stars ratings provide a good quality indicator for those choosing a plan. Check out the article here. Nona Tepper Modern Healthcare

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Will #valuebasedcare save #healthcare? That has been a popular message for what seems like at least a decade at this point. A good portion of the argument focuses on moving payments to #clinicians away from volume, but to outcomes and quality. Those are good goals and should be a focus because #patient care should be proactive, not focused on how to maximize the economic potential from each visit. However, widespread adoption remains slow and behind so many previous estimates. CMS has tried advancing the ball with #Medicare with mixed results. What can or should drive a faster pace of change? That remains an open question. One approach could be just ripping the bandaid off and removing the optionality. Operating in two worlds is difficult and enables staying in the familiar. Time will tell if a different approach will be taken. https://lnkd.in/eVEV7KTR

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…and private equity wants in on the action. Well that makes sense 🙄 Turns out running a hospital is very, very hard. A 4.3% margin is not healthy, even for a non-profit. Payors and pharma continue to point the finger at these “rich” hospitals and complain about market consolidation, 340B, and any number of other phantom problems, but in reality most are just trying to survive. Many of these grievances are gaslighting in its purest form. Those making it work are focused on the basics. The strategic plan has highly pragmatic, common sense initiatives that return a tangible benefit with clear measurable targets as opposed to chasing trendy buzz words. They control labor and they control drug cost. On the pharmacy side, they deeply understand the economics and have an appropriately positioned business minded, strategic pharmacy leader. #pharmacist #pharmacy #hospitals #healthcare https://lnkd.in/g9d9VTcK

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In any #patientexperience scenario, ACCESS is number one. Agree? You're the Chief Marketing Officer at any health system USA. Your C-suite just signed a deal with private equity to move primary care to concierge medicine. Your charge is to drive conversions for people to pay $2000 to $4000+ for prime access to a physician. As CMO, you do what you are told to do. Your target audience is easy. People with the means to pay extra. In any region or location, you know who they are. Tracking and measurement is simple, too. The CFO will know how to validate this ROI. The bigger question...is this trend to shore up and protect traditional primary care the right thing to do? * Will it improve access? No * Will it lessen consumer demand for physicians? No * Does it solve health equity issues? No * Is it about 'health' or chronic disease management? No * Are patients the priority? No. They are directed to other options and urgent care if they can't afford the concierge deal. * Does it sound more like socialized medicine? Yes. (e.g. - in the UK, you can buy individual private insurance while the masses are left to the government's cumbersome national health plan.) * The 'haves' vs. the 'have nots' continues to grow? Yes * Does the provider really make any revenue? ?? * Do private equity firms fill their coffers? Yes * Do the comments in the article make you cringe? Yes, yes! As I've reported previously, the patient experience is suffering. We all talk the latest good game to solve the problem. Is this the answer? #healthcare #hospitals #primarycare #physicians #patients

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Busy few months in Healthcare! From Optum closing its Telemedicine Unit, Walmart and Walgreens closing Primary Care Clinics, and Teladoc & Livongo stocks sliding. With all of this, there have been a myriad of comments on where the market is going ranging from Telemedicine is a dying modality and in person care is back, to Primary Care is in trouble. It’s important to realize that the changes that we’ve seen do not all share the same root cause. FIRST, point solutions, which focus only on an isolated part of the patient care journey, which initially received a lot of hype in the US market, have now been shown to have questionable ROI and actually tend to add complexity in the form of “we have an app for that,” which contributes to the plague of care “un-coordination” as well as increased costs and worse patient outcomes. We don’t need a solution that takes care of diabetes. We need a system that takes care of a patient with Diabetes. We don’t need a solution that especializes in taking care of Depression, but yet one that addresses all the needs of a patient with Depression, that may have Diabetes and Hypertension, as well. Therefore, my prediction is that in several years, point solutions will be a thing from the past. SECOND, Walgreens, Walmart and others missed the lesson where Nisha Mehta, MD brilliantly said: “You cannot scale your way out of America’s healthcare problem”. This idea that you can fix all problems from preventive medicine to management of complex diseases with scale is absurd. Why some entities like Oak Street Health and ChenMed are having a relative success when comparing to others that are exiting the market? The answer is clinical work flow! A lot of players have been banking on Medicare advantage for success. Unfortunately, these players entered the Medicare Advantage market with outdated clinical work flows while attempting to serve both a fee per service population and one under value based arrangements, what is nearly impossible to achieve (and scale didn’t help!). They were wrong. I don’t think we need to put into question the future of telemedicine, but yet the future of consumerism. Therefore, No! Telemedicine is not returning to the business as usual of the pre-pandemic era and it’s use in very limited clinical situations. Both telemedicine and remote patient monitoring (the latter to a larger degree) will continue to expand. However, this expansion will likely come from its incorporation into redesigned clinical workflows by traditional players like Hospital Systems and Large physician Groups. That will occur in both low acuity situations like preventive medicine and mental health all the way to management of complex conditions like cancer care and initiatives of Hospital at Home. So, YES! Telemedicine and Remote Patient Monitoring are here to stay, the questions are: (1) In what format? (2) Will patients have a voice in the redesign of this new way of delivering care?

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Yep, it takes lots of hard work as well as perseverance and persistence combined with great talent and luck to have a chance to be successful in the healthcare space. Not the least being spot on timing. Today’s healthcare scene is fraught with ever increasing demand and dwindling supply. I spent 50 years in both the tech sector and services sector with some very good outcomes and some marginal ones. I have enormous respect for those in management and those financial sponsors willing to take pretty significant risks. For as expensive as healthcare spend is today it’s only get worse and not better but with very marginal returns. The fact that a company the size and magnitude of Walmart shut down its healthcare speaks volumes. I for one expected a much different outcome but their departure puts a definite marker on just how challenging this healthcare industry is today. My answer to solving it is pretty straightforward, change, sacrifice and move quickly on any front where progress isn’t inevitable.

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