Woodrow A. Myers Jr MD MBA

The Association of Healthcare Value Analysis Professionals (AHVAP) celebrates Elizabeth Eisenberg, MSN, RN, CVAHP from Scripps Health for commitment to excellence in the specialty of healthcare value analysis! Liz has signified this commitment by signing the official Association of Healthcare Value Analysis Professionals (AHVAP) healthcare value analysis pledge. To learn more about the Association of Healthcare Value Analysis Professionals (AHVAP) Commitment pledge: https://lnkd.in/gqEWPBue. #AHVAP #valuebasedcare #excellenceincare #valueanalysis

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What does calling my cable company have to do with Medicaid? I had to call a certain notorious cable/internet provider recently. The one with customer service so bad that it was skewered in a classic South Park episode. I blocked out an hour and braced for my inevitable PCOM aneurysm rupture. Shockingly, it was a breeze. The rep was friendly, and my issue vanished in minutes—a far cry from their usual 'dial-one-to-scream-into-the-void' reputation. So, what changed? Competition happened. A decade ago, our choices for cable and internet were as limited as the soda options in a health spa. Now, thanks to a buffet of streaming services—even including live local TV—the old cable giants had to step up their game or step aside. Turns out, competition is more effective than caffeine at improving service quality. Why can't Medicaid beneficiaries get the same treatment? Currently, most Medicaid coverage is through Managed Care Organizations (MCOs), where the state pays a fixed monthly rate per patient. This model should spur cost-efficiency, but it often just limits the scope of care. Low payments to doctors, restricted access to necessary services—who does that help? Could strict government regulations guarantee better service? Maybe, but FA Hayek (and a basic reading of history) prove that bureaucracy alone can't engineer excellence. And choice for Medicaid patients? Virtually non-existent. Many areas offer just one MCO. If you're dissatisfied, too bad—there's no alternative. It's like being stuck with dial-up in the era of fiber optics. Long wait times for basic procedures, no freedom to seek better coverage... It's eerily reminiscent of the old cable monopoly days. In the private sector, at least there's a semblance of choice: HMOs, PPOs, HSAs... But for Medicaid recipients? Sorry, the state chooses for you. Hope you like it. Our Medicaid system desperately needs a dose of competition. Isn't it time we offer Medicaid patients the luxury of choice that drives quality up and costs down? https://t.co/C7XE6CpIIP Joe Grogan Lisa Grabert Joanne Spetz Cheerag Upadhyaya, MD, MBA, MSc, FAANS, FACS Brian R. Gantwerker, MD, FAANS, FACS Sanjay Dhall Larry Bucshon, M.D.

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It's wild to think in 2024 we're FIRST seeing the DOJ accuse telemedicine conglomerates of criminal drug distribution. How long have we known about these practices in brick and mortar care...? Answer: decades! Take it from someone who prescribed stimulants and other psychotropics to kids over the years - painstakingly measuring and documenting the need and impact - these appalling abuses by Done and Cerebral mean we need more calls for thoughtful pause when it comes to working with startups. Particularly about funding's role - my favorite topic! 🤑 How did we end up with venture capital and PE financing in healthcare that risk the safety of kids in the name of exorbitant returns? Not that all VC or PE dollars are bad, of course, but they're certainly key drivers who shouldn't be in that seat. Did we underestimate these funders as 'barbarians at the gate', much like the pharma reps of the 90's and early 2000's heyday? Have we not learned from Purdue Pharma's aggressive and deadly Oxoycontin marketing? Purdue pleaded guilty to criminal charges and paid $600 million in fines in 2007. Or TAP Pharmaceutical Products's Lupron kickback scheme for the prostate cancer drug? TAP also pleaded guilty to criminal charges and paid $875 million in fines in 2001. Or Pfizer marketing Neurontin, an anti-seizure drug, for off-label uses, such as treating pain and bipolar disorder, even though the drug was not approved for these purposes, and paying physicians kickbacks. In 2004, Pfizer pleaded guilty to criminal charges and paid $430 million in fines. Cerebral and Done's playbooks were practically the same thing, just with a modern mid-pandemic, low-regulatory scrutiny, digital-platform twist. Will appropriate regulation ever outpace American venture greed? Is it even possible to ensure patient safety AHEAD of tragedies driven by the intersection of innovation and venture funding? If you're keeping score, healthcare regulatory reactivity: 1 million. Healthcare ounces of smartly preventive policy: 3. Blech. 😖 When will we finally own that prevention in-house? #healthcare #overdoseprevention #suicideprevention

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Proof of Purpose; PDPs kept afloat Good for Manufacturers, too? The intricacies of IRA Part D benefit redesign dramatically reshape the OOP for millions of beneficiaries, reducing financial toxicity and raising utilization (I will post to past non adherence figures in comments) Unlike MA PDPs, freestanding PDPs can’t shuttle money over from the medical benefit to moderate premium increases, so some speculated that PDPs would fail. I commented several times that given this administrations view of the private market exemplified by MA that was highly unlikely. And after all PDPs are holding up half the benefit. CMS moves forward. “CMS is also announcing a voluntary demonstration program for standalone prescription drug plans (PDPs). The Part D Premium Stabilization Demonstration is designed to test whether additional policy changes stabilize year-over-year changes in premiums for participating standalone PDPs, leading to more predictable options for beneficiaries during the initial implementation of the IRA’s) benefit improvements, creating more gradual enrollment changes… Under the voluntary demonstration, there will be a reduction in the base beneficiary premium of $15 for all participating PDPs, combined with a year-over-year plan premium increase limit of $35 and narrowed risk corridors..” Thanks Tom Thoughts on implications, such as spillover from reducing headwinds, moderating adoption of narrower formularies and networks? If so possible plus for Phrma —not to mention if it slows down MA train with attendant Part B drug prior auths. #PartD #PDPs

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One of the main questions I am asked since the election is about expectations for the Centers for Medicare & Medicaid Services Innovation Center (CMMI) and whether to expect continued support for the shift to value-based payment models under the new Trump admin. The short answer is yes -- I fully expect the new administration to be supportive of #valuebasedpayment reform but recognize that model priorities and, importantly, messaging are likely to change. Why? Because they usually do. Since the ACA established CMMI and the MSSP (CMS' flagship, permanent ACO model), each presidential admin has strongly supported the shift to VBP. Support for the shift to "value" even predated CMMI, with HHS Secretary Michael Leavitt and CMS Administrator Mark McClellan under President Bush. Recognizing that Trump 2.0 will be quite different relative to his first term, it is still helpful to look back at the activities under the first Trump admin. Not only does it help to reveal potential philosophies about payment reform, but it also tells us about the importance of individual leaders — particularly HHS secretary and CMMI director. Trump's first HHS secretary Tom Price, a former orthopedic surgeon, was not vocally opposed to VBP, but he wasn't a clear proponent of these models either. Among his first actions were rolling back a few mandatory models announced at the end of the Obama admin. (Each admin begins with a comprehensive review of CMMI's portfolio and adoption targets, looking for ways to make their own.) Under Price, we saw the broader market tap the brakes, waiting to see if Medicare's shift to value was here to stay. In 2018, Price was replaced by Alex Azar who appointed Adam Boehler to lead CMMI and their embrace of value was crystal clear. Boehler was quoted on more than one occasion as saying he wanted to "blow up FFS." The duo announced several models (see 2nd slide below), many of which embraced higher levels of downside risk, while also advancing models focused on opioids and kidney disease (an area of particular importance to Azar). With the Biden admin, we saw CMMI continue to advance alternative payment models, also with a focus on bringing in more safety net providers and underserved populations, and leveraging state-based models to catalyze regional transformation using multi-payer alignment. It remains to be seen who will lead CMMI, though I expect it will be someone akin to Boehler--a private sector leader and possibly a founder of a risk-based delivery organization--who will continue to push the shift to value. We will almost certainly see less emphasis on health equity, but I expect a continued focus on scaling accountable care and bringing in specialists. It's important to remember that the shift to value is not politically motivated but an economic imperative. So, while models and messaging vary, expect continued bipartisan support. *Correction to models on slide 2. CPC+ should be Primary Care First (PCF), its successor.

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Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

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My next Signal takes a closer look at the latest antitrust probe into large dialysis companies and the shifting role of non-competes in kidney care. A recent POLITICO article provides helpful background around topics like NCAs in dialysis and impacts on the adoption of home dialysis technologies. This is an important discussion, so I'd love to hear from you. If you have something you'd like to share, whether it's an anecdote, comment or question for other readers, please leave a comment or send me a message. H/t to Tom Mueller for sharing the article last week. https://lnkd.in/e95a23JF

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CMS’ “Year 2” IRA Guidance Concedes Agency Patient Engagement Has Been a Bust A number of patient groups have quietly expressed frustration with #CMS’ “listening sessions” on the #InflationReductionAct “fair price” negotiations. If you read CMS’ “year 2” guidance carefully, it effectively admits the patient complaints are real and legitimate. The Complaints: Patient groups sat on the sidelines in the litigation challenging the constitutionality of the IRA, at least in part, because they believed that they could shape IRA implementation through agency engagement. But some groups are now expressing frustration. They expected CMS to explain how it was approaching negotiation and the underlying evaluation of the selected drugs. With that context, they expected to be able to provide meaningful feedback to CMS’ plans and preliminary assessments. According to the groups I have spoken to, that is not how things have gone. CMS is tight-lipped—in “listen only” mode. Unclear what CMS is considering and how it sees the “value” question, “patient interaction” on the IRA has devolved into CMS and patient groups staring at each other blankly. Confirmation: When you read the “year 2” guidance, it confirms the patient complaints. Deploying diplomatic “regulatory speak”, CMS says it “intends to improve upon the design of the patient-focused listening sessions”. Note the reference to “listening sessions”—confirming the agency has been in “listen only” mode. CMS admits the need for change, saying it “is soliciting comments from interested parties on event format, scope, and logistics”; it then indicates it “is considering events where there is discussion among speakers and in which CMS may ask clarifying questions”. But even this proposal isn’t getting to the core of the problem—patient groups shouldn’t have to be expert mind readers regarding CMS’ intent based on a few interspersed “clarifying questions”. CMS offers some other alternatives, too: “CMS is also weighing different event formats, such as round table sessions on broader topics with a mix of speaker types (e.g., patients, providers, and health data experts) or focus groups on targeted topics with one speaker type (e.g., patients or caregivers)”. But all that doesn’t commit CMS to doing any speaking. Just that others—patients, providers, and “experts” will be asked to speak. Patient groups can’t react in, or to, a vacuum. No Time: The guidance concedes that they can’t fix the problem for “year 1”. After all, July 31, 2024 is the deadline for manufacturers of selected drug to accept or reject CMS's final MFP offer. Indeed, CMS acknowledges that its proposed changes in patient engagement will be effective only “for…price…year 2027”. So, in another words, at least for “year 1”, we are going to get “fair prices” that don’t reflect meaningful patient input. #drugdevelopment #drugpricing #Medicare #managedcare #rarediseases #patientsfirst #lifesciences

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Walmart joins so many others in quickly entering and leaving or scaling back in healthcare after ambitious plans to scale. This morning, Walmart said it will close all 51 of its health-care clinics, as well as shut down their telehealth virtual care services. This is right after an announcement in March that they wanted to double the size of their clinical operations by opening up over 20 more locations this year and more next year. The reasons they cited? “Like others, the challenging reimbursement environment and escalating operating costs create a lack of profitability that make the care business unsustainable for us at this time.” As a physician, it’s been fascinating to watch over the past few years as so many non-medical companies try to get their bite of the huge percentage of the GDP that is healthcare. They pour money into trying to deliver healthcare at scale, ignoring the many concerns that hospital systems and physician private practices have been citing for years: declining reimbursements, shortages of clinicians, and expensive labor costs. Healthcare is broken, and those that are in it understand why. Patients need - and deserve - quality health care. This requires safe staffing practices, skilled clinicians who can feel good about what they do, and insurance companies that pay their bills. We can’t have a system where insurance companies can get away with record profits while finding more and more reasons not to pay for care and eroding away at the heart of healthcare. You cannot scale your way out of America’s healthcare problem. You actually need to fix the incentives, regulate insurance companies, pay clinicians appropriately, prioritize clinician well being and retention, and focus on the patient. The days of paying lip service to physicians leaving medicine and physician burnout are numbered. Supply and demand forces will necessitate real solutions that move the needle. Companies will come and go in the healthcare space when they realize how hard it is on the ground in healthcare these days. The question for patients and legislators is, who will be left to pick up the pieces if there’s no support for physicians, other healthcare workers, and hospital systems?  The percentage of clinicians leaving healthcare annually because they no longer recognize the heart of why they joined the profession is astounding, with over 1/4 of clinicians looking to leave within the next few years. Relying on the altruism of clinicians and the erosion of quality healthcare to support profits for corporations is just not a sustainable business model in healthcare - not to mention terrifying for public health. #HealthcareOnLinkedIn #PhysicianBurnout #PhysicianShortage #Walmart

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New study in #HSR from Yevgeniy Feyman PhD et al  measure specialty provider networks in Medicare Advantage (MA) and examine associations with market factors. WHAT IS KNOWN There is limited evidence on the relationship between MA network breadth among specialists and plan or market factors. WHAT THIS STUDY ADDS Using a recently developed algorithm for measuring the restrictiveness of primary care providers, this study measures the network restrictiveness of nine high-prescribing specialties among MA contracts. CONCLUSION Findings suggest that rural beneficiaries may face disproportionately reduced access in these networks and that efforts to improve access should vary by specialty. FULL ARTICLE: https://lnkd.in/gnn6Uwmk Wiley AcademyHealth #HSR 

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As we settle into our regular fall routines, I’ve been thinking a lot about the state of healthcare so far this year and what I hope we can continue working towards as an industry in the final months of 2024. First, Surescripts latest data report backs-up the anecdotes we’ve all heard about how healthcare is hurting. But it also highlights how the industry can collaborate to eliminate barriers and enable meaningful health intelligence sharing between clinicians. The result? More accessible care for patients in communities across the country. Check out all of the insights we’ve gathered from our annual clinician survey and more trends in our full report -- link in the comments.   Next, healthcare technology innovation and interoperability: this is a big one. Last year, Surescripts supported 24 billion exchanges of patient clinical and benefit information, connected 2.14 million care providers and organizations that reached more than 99% of the U.S. population. This means clinicians spent less time searching for patient information – sending faxes or making phone calls to get what they need to make safe, quality and less costly care decisions with their patients. But we have so much more to do: pharmacists and other clinicians still say it is somewhat or very difficult to share patient information securely and confidently with other care providers (46% of pharmacists and 31% of other clinicians). And clinicians hope to see better access to clinical information: 85% of pharmacists and 57% of other clinicians said that they would place a high priority on connecting both pharmacists and prescribers with centralized information about their patients. We know that secure health intelligence sharing is essential for true care collaboration that improves patient care. We will be working alongside the The Sequoia Project's new Pharmacy Workgroup under the Interoperability Matters program. The goal is to advance interoperability and allow clinicians, including pharmacists, to have access to key clinical insights that help them provide care for their patients. Check it out at the link below. Lastly, I’m reassured and hopeful. Despite the differences in the services they provide, the clinicians, health plans and advocacy organizations who came together for the Evolving Care Team Summit in D.C. earlier this summer proved that, not only can we have meaningful conversations about ways to work better together, but we really do share the same goal of improving patient care. I hope this meeting will continue to inspire us to find ways to collaborate across the industry on issues like reimbursement and access to needed health intelligence for clinicians working as a team. It's this kind of collaboration that can help patients get the care they need and deserve and ultimately, it’s also how we can help healthcare heal itself.

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Now that the drama of the UK general election is over, many eyes are turning to the forthcoming US election. This article and the upcoming webinar from my US colleagues will focus on implications for healthcare of Harris vs Trump - one to watch for sure...... #avalerehealth #marketaccess #healthcare

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Loper and #Medicare #Reimbursement: What Does the Future Hold? Ganny A Belloni from Bloomberg News wades in (in a terrific article) on the implications of #Chevron and the rise of #Loper on Medicare reimbursement issues. I'm quoted. My take? I think, as I say in the article, Loper will have less impact than people think. Loper eliminates Chevron “deference” by a court to an agency’s interpretation of a federal statute, where that law is “ambiguous”, meaning it can reasonably be read in different ways. Congress can (and will) significantly reduce the risk of litigation challenges in a Looer world by, as Ganny summarizes the point, defining statutory terms more precisely and "more clearly and explicitly giv[ing] the agency the discretion to decide issues". Further, many potential challenges can be avoided by CMS, as I say in the article, by framing "more ... [agency] decisions as ‘factual determinations’ or ‘adjudicative’ questions, where it still is entitled to deference, even after Loper.” To those of you who are fans of the administrative state, take heart. The sky, truth be told, is not falling. #healthcare Centers for Medicare & Medicaid ServicesU.S. Department of Health and Human Services (HHS) #CMS #HHS #APA #administrativestate #agencydiscretion #rulemaking #agencies #administrativelaw

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What does health insurance do? The conversation in the attached screenshot sums it up. We have a distorted market in healthcare. For drugs, there is a middleman called PBM between the insurance and the drug companies. The PBM negotiates a higher rate than the cash price - usually 2x or 3x and then receives an under the table rebate from the drug company. It passes of portion of this rebate to the insurer. The end effect is that the bottom price for the consumer is increased. The consumer believes that their insurance saved them a lot of money. #healthcare

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Digest this https://lnkd.in/ehPYvaeH. As I and others have stated many times before, Medicare fees for physician patient services are not the problem. Yet, physicians continue to be squeezed as low hanging fruit. Time for Congress and our government officials to open their eyes and get to the bottom of our healthcare financial crisis and stop punishing the people who care and work the hardest and deserve the most: physicians. Remember, this discussion is not about the importance of allied healthcare workers and nurses and other providers in the system. This is about participating Medicare physicians being punished with reduced payments year after year while hospital systems, pharmaceuticals, insurers, and suppliers make out like bandits at the expense of adequate healthcare for the consumer: our patients.

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'PRIVATE INSURERS involved IN the government’s MEDICARE ADVANTAGE program MADE HUNDREDS OF THOUSANDS OF QUESTIONABLE DIAGNOSES THAT TRIGGERED EXTRA taxpayer-funded PAYMENTS from 2018 to 2021, including outright wrong ones, a Wall Street Journal analysis of billions of Medicare records found, RESULTING IN TENS OF BILLIONS OF DOLLARS IN EXTRA COST. The questionable diagnoses included some for potentially deadly illnesses (such as AIDS), for which patients received no subsequent care, and for conditions people couldn’t possibly have, the analysis showed. Often, neither the patients nor their doctors had any idea. Medicare Advantage, the $450-billion-a-year system in which private insurers oversee Medicare benefits, grew out of the idea that the private sector could provide healthcare more economically. It has swelled over the last two decades to cover more than half of the 67 million seniors and disabled people on Medicare. HOWEVER, instead of saving taxpayers' money, Medicare Advantage HAS ADDED TENS of BILLIONS of DOLLARS IN COST, researchers and some government officials have said. ONE REASON IS THAT THE HEALTH INSURER CAN ADD DIAGNOSES to ones that the patients’ own doctors submit. Medicare gave insurers that option so they could catch conditions that doctors neglected to record. The Journal’s analysis, however, found MANY DIAGNOSES WERE ADDED FOR WHICH PATIENTS RECEIVED NO TREATMENT, OR THAT CONTRADICTED THEIR OWN DOCTORS' ASSESSMENT.' For example, UnitedHealth members were about 15 times as likely to have that diagnosis of diabetic cataracts as the average patient in traditional Medicare, the Journal analysis found. Eye doctors interviewed by the Journal said it was implausible that such a large share of UnitedHealth’s patients could have the relatively rare disease. The government paid all Medicare Advantage insurers more than $700 million from 2019 to 2021 for diabetic cataracts. Most of the diagnoses were added by insurers. SOME DIAGNOSES claimed by insurers WERE demonstrably FALSE, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery, which replaces the damaged lens of an eye with a plastic insert. “It’s anatomically impossible,” said Dr. Hogan Knox, an eye specialist at University of Alabama at Birmingham. “Once a lens is removed, the cataract never comes back.” And insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated generated $8.7 billion in 2021 payments to the company, the Journal’s analysis showed. UnitedHealth’s net income that year was about $17 billion. The Wall Street Journal consulted more than a dozen experts, including academics, actuaries and policy analysts, about its analysis of the Medicare data, who said the methodology was sound.

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I’m thankful that I could share my thoughts at that very hearing. There is so much misinformation about 340B. For me, it comes down to two main points: 1- if hospitals need that money as a subsidy to fund everyday activities, they should just ask for a subsidy. Let’s open up the books of these institutions, which already get a huge subsidy with their non-profit status, and see why they are running in the red. Are they really losing money on Medicaid patients or are they just bloated and inefficient? 2- let the subsidy follow the patient. This is a drug benefit program. Why does the funding go to an institution? Imagine if we did that with SNAP, giving a bunch of money to large restaurant chains in exchange for their promise to use the revenue to provide food for poor people (with no oversight to ensure that’s done). We don’t do that; instead we give the benefit to the person who needs it. Let’s change 340B to match that model. Adam J. Bruggeman, MD, MHA, FAAOS, FAOA Daniel Choi Colin Yokanovich John Strom Peter Stein Adam Fein Deborah Williams Lisa Grabert Maya Babu, MD, MBA Katie Orrico Larry Bucshon, M.D. Ann M. Richardson, MBA

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I’ve been given advice that the fastest way to monetize HER Heard without charging the end user (woman) is trackers and selling data. Instead, I’d like to build something more trustworthy. I don’t want to be in a headline like this. If you are not paying, then you are the product (you/your data are being sold). There are newer ways to deindentify data or even to aggregate things women search for that can be of interest to various stakeholders. In theory that could be okay to sell, but in a post-Roe world with laws encouraging bounty hunting, I am vetting the choices ahead. I am all for moving fast, without breaking things.

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