What You Should Know: 

– UnitedHealthcare and RUSH Health announced a new relationship that will give UnitedHealthcare Medicare Advantage plan members network access to all RUSH Health locations in Illinois for the first time, effective immediately. 

– The multi-year agreement, effective Oct. 1, provides UnitedHealthcare Medicare Advantage plan members with enhanced access to quality care and provides a new option as they choose which health plan best meets their healthcare needs during the current Medicare Annual Enrollment Period.

– The new agreement covers nearly all UnitedHealthcare Medicare Advantage plan types, with the exception of Medicare Advantage Access plans.

RUSH Health Background

RUSH Health is a clinically integrated network of physicians and hospitals that work together to provide high-quality, efficient health services. The health system covers the spectrum of patient care from wellness and prevention to disease and care management. At the system level, RUSH Health includes RUSH University Medical Center, RUSH Copley Medical Center, RUSH Oak Park Hospital, Riverside Medical Center and more than 140 physician practices.

In Illinois, UnitedHealthcare serves more than 186,000 people enrolled in Medicare Advantage plans with a network of thousands of physicians and other care providers statewide. 

“This new relationship will create greater access to the very best health care for more patients across the Chicago area and Northwest Indiana,” said Lisa Wagamon, president of RUSH Health. “We are pleased to be able to extend the reach of academic medicine to more patients and families, especially those who need care for serious and complex conditions.”

What You Should Know:

• MultiPlan, a provider of data-enabled cost management, payment, and revenue integrity solutions for 700+ healthcare payors announced the acquisition of Benefits Science LLC (BST) for $160M in cash and stock.
• BST was founded in 2012 by a group of MIT-trained experts in data science, including Dimitris Bertsimas, Ph.D., who is recognized as an early pioneer in healthcare analytics and who serves as the company’s chief data scientist. Dr. Bertsimas will continue with BST post-closing. Today, BST’s machine learning algorithms and AI software help about 75,000 employers to predict future risk and manage health plan decisions.
• As part of the acquisition, BST will form the foundation of MultiPlan’s new Data & Decision Science service line by adding new decision analytics and software solutions that intersect with high customer demand and limited competitive offerings.

Acquisition Accelerates Launch of New Data & Decision Science Service Line 

The acquisition of BST strengthens MultiPlan’s foothold in large and fast-growing adjacent markets by unlocking the value of its significant and expanding claims flows for in-network commercial, Medicare Advantage and other government programs, property and casualty, and supplemental insurance markets.

Key products BST brings to MultiPlan’s new Data & Decision Science service line include:

• Price Transparency – a modern self-service software platform jointly developed with MultiPlan that provides prescriptive analytics and applications to help customers benchmark network performance, optimize network design, and improve competitive positioning. In less than a second, the solution can query over 500 billion records of machine-readable payor and provider pricing data now required by regulation to be made public. The solution will aggregate this vast contracted rate information and enrich it with MultiPlan’s extensive proprietary demographic and affiliate data on 1.3 million contracted providers, pricing technology, and deep clinical billing expertise.
• BenInsights – a modern software platform for employers and their consultants that quickly and accurately aggregates a plan’s data and provides highly flexible financial and clinical reporting and decision tools through a self-service software platform. BenInsights also integrates predictive risk modeling and prescriptive analytics and value-added services, such as benefit plan design and optimization.
• Risk Analytics & Insights – solutions that complement existing actuarial-based modeling by applying interpretable risk models, risk scoring, and prescriptive analytics for commercial and government health plans. Among other services, risk scoring can seamlessly attach to MultiPlan’s prepayment claims flows to help identify emergent risks by individual, group, or condition, and prescribe financial and clinical program enhancements across a plan sponsor’s organization.
• Other Market Solutions – a group of software solutions for supplemental insurance carriers and stop loss carriers, including digital claiming, digital underwriting, and targeted selling tools, that help improve plan performance and competitive positioning.

Financial Terms

Under the transaction agreement, MultiPlan will pay a consideration of $160M, comprised of $140.8M in cash and 21.6 million shares of MultiPlan common stock to acquire BST. Additionally, MultiPlan will establish a long-term incentive and retention program pursuant to which BST’s management team is eligible to receive target payments of $66M over three to five years, subject to ongoing service to MultiPlan and to adjustments based on performance relative to annual recurring revenue targets. BST is projected to generate revenues of approximately $16M with breakeven profitability in 2023. MultiPlan expects the acquired company to contribute over $100M of incremental annual revenues within the next several years and to approach corporate-level profit margins at scale.

As the healthcare industry continues to evolve, there is a growing need for innovative solutions that not only improve the quality of care but also make care more accessible. Non-emergency medical transportation (NEMT) plays a crucial role in helping patients get to where care is delivered. As healthcare reform efforts continue to gain momentum, transportation benefits have become an increasingly critical component of providing equitable care to patients. NEMT helps close the health equity gap by ensuring all patients can access care, regardless of their location, medical needs or transportation options.

In recent years, technology has played a significant role in the advancement of the NEMT industry. Modern NEMT solutions streamline the ride booking and scheduling process, introduce new modalities, improve the overall experience for patients, and decrease fraud, waste and abuse (FWA). For decades, the industry lacked a patient-centric approach focused on efficiency, reliability, and accessibility for all populations, especially those enrolled in Medicare Advantage and Medicaid plans.

A reliable NEMT program can help health plans reduce administrative burden, lower the number of missed appointments, and ensure that patients receive the right level of care and support at the right time during their healthcare journey. Using integration services, health plans can integrate NEMT solutions and programs directly into existing platforms to better manage the member experience and provide an extra layer of connection for members when they utilize these benefits.  

By collaborating with innovative NEMT partners, health plans have made great strides to enhance the overall member experience. Historically, the member journey was largely overlooked, limiting members to two-day-plus advanced notice or long wait times for rides. With the introduction of on-demand ride-booking services through rideshare partners like Uber and Lyft, member needs are prioritized and personalized. Patients can book a ride when and where they need it; then, plans receive real-time updates and notifications during a member’s ride and can make any necessary adjustments as needed. Real-time ride monitoring helps reduce stress and anxiety for patients, prevents FWA, and ensures every ride has a digital record complete with geolocation at every step of the journey.  

While technology-first NEMT has advanced rapidly over the past few years, we’ve only begun to scratch the surface of how it can revolutionize care accessibility. As Medicare Advantage and Medicaid plans continue to grow, NEMT partners will play an increasingly important role in scaling transportation benefits. By working with healthcare providers and payers to integrate NEMT benefits into existing programs and systems, we can provide high-quality transportation services to our most vulnerable populations.

Given the proximity to high-acuity and underserved patients, who are commonly enrolled in Medicare Advantage and Medicaid plans, it’s important to determine whether a transportation provider has the capacity and expertise to meet the individual needs of each member. In a recent study, 21% of U.S. adults without access to a vehicle or public transportation skipped needed medical care last year. This experience is shown to vary depending on other factors such as race and ethnicity, household income, urban or rural location, disability status, and more. Expanding ride modalities with options like on-demand rides provides members the flexibility and comfort they’re looking for in an increasingly-consumer driven healthcare environment as well as plans with the tools they need to close these health equity gaps in accessing care for a diverse population. 

By offering members benefits that work for them and their unique needs, plans can focus on increasing benefit utilization and improving critical present and future Stars Ratings benchmarks like member experience and health equity. When measuring a program’s effectiveness, vendors and plans must work together to decide which data to capture, determine what’s working, and identify areas for improvement. Technology-first NEMT plays a critical role in capturing data and turning it into metrics that matter. 

Despite great strides made to help address the social determinants of health (SDoH), such as transportation access, government regulations continue to play a critical role in shaping the industry’s growth and impact. Various regulations, such as the Medicaid Non-Emergency Medical Transportation Benefit and the Americans with Disabilities Act, have positively impacted how patients access care and the quality of transportation services provided by NEMT vendors. These regulations are crucial for individuals who may not have reliable transportation options, especially those living in rural or low-income areas, and help ensure NEMT providers meet specific quality standards and are held accountable for providing safe and dependable transportation services. As the NEMT industry continues to evolve, it is important for providers to stay informed about the latest regulations and to work closely with government agencies to ensure they are providing the highest quality transportation services possible. By doing so, they can help close the healthcare equity gap and ensure all patients have access to the care they need.

While we can’t predict all the roadblocks the healthcare industry will face in the future, it’s clear that a more efficient, reliable and cost-effective NEMT solution will continue to drive better outcomes for health plans and patients. 

About Andy Auerbach

Andy Auerbach is the Chief Revenue Officer of SafeRide Health, the leading technology-first platform connecting patients to care one ride at a time.

What You Should Know:

• 2023 started off with the hallmarks of a rebound year. While Q4 2022 signaled the tail end of the digital health funding cycle, January and February funding numbers began to suggest that sector investment was slowly but surely inching back upwards. Inflation was easing ever so slightly. Investors were rediscovering their confidence and launching new projects, signaling optimism in the sector, according to a new Rock Health report.
• However, recent news—the collapse of Silicon Valley Bank, the seizure of Signature Bank, Moody’s downgrading of bank credit ratings, and another Fed rate hike—was a stark reminder that the choppy waters of 2022 aren’t over yet. 

Key Trends and Insights from Q1 2023 – Digital Health Funding

There’s no denying that Q1 2023’s economic conditions, bank scares, and regulatory changes have digital health startups of all sizes nervous, whether they’re trying to raise their next funding round or waiting for the right time to exit.

The following key trends from Rock Health’s report are a review of the venture, banking, and policy waves breaking within digital health, coupled with insights regarding the volatility of the modern-day regulatory landscape, how the financial market seems different for everyone, and how small-scale startups have it the hardest.

Q1 Funding Soars, But 2023 May Struggle to Catch Up to 2019

Q1 2023 U.S. digital health funding closed with $3.4B across 132 deals, with an average deal size of $25.9M. While this quarter exceeded both Q4 2022’s $2.7B and Q3 2022’s $2.2B funding pots, Q1 isn’t enough to signal a new “bull run.” If funding for the next three quarters matches the average funding across the prior three quarters, 2023 is on pace for the lowest level of annual funding since 2019. The truth remains that the founder-friendly market of 2021 and early 2022 has tilted sharply toward investors.

Notably, within its $3.4B raised, Q1 2023 saw heavy representation of mega deals. After only six digital health raises over $100M across Q3 and Q4 2022 combined, Q1 2023 logged six megadeals from Monogram Health ($375M), ShiftKey ($300M), Paradigm ($203M), ShiftMed ($200M), Gravie ($179M) and Vytalize Health ($100M)—accounting for 40% of the quarter’s total digital health funding.

Silicon Valley Bank’s Collapse

SVB’s collapse nearly precipitated a liquidity crisis in the sector, and concerns circulated that startups might need to engage in distressed debt buys or raise emergency bridges—possibly with “lender-friendly” terms or at slashed valuations—in order to secure working capital. It’s worth pointing out that not all digital health startups carried the risk burden equally. Startups with well-established investors were more likely to have the assurances of cash floats and level-headed perspectives from advisors who have been around the block a few times, while those with greener syndicates were left unsure of whether their own funders could even weather the storm.

After seeing their investors operate in crisis mode this March, several digital health founders may feel compelled to re-evaluate their cap tables and possibly move forward with different investors for future raises. Startups were left with another conundrum after SVB’s collapse—which banking institution to choose next. SVB was known to offer startups loans during high-growth periods and took on companies that were too early to demonstrate product-market fit. While late-stage startups likely have the capital and credit requirements to bank with high-street institutions, nascent teams or those based outside of the US will need to turn to more restrictive and expensive alternatives to establish financial operations and secure loans.

The IPO Market and Q1

Q1 2023 logged another quarter with zero digital health IPOs. Digital health stocks started 2023 trading almost 50% lower than they did at the start of 2021, pushing some recently-exited players like Pear Therapeutics to explore going private. No later-stage digital health players felt compelled to venture into IPO territory this quarter, fearing that the market would yield bottom-barrel issue prices.

In December 2022, healthcare data startup Komodo Health raised $200M alongside a restructuring plan that laid off 9% of its workforce. In January, hybrid care provider Carbon Health closed a $100M Series D while also trimming its RPM and chronic care divisions and completing its second round of layoffs.1 That same month, nurse staffing solution Shiftkey announced its $300M raise, accompanied by a quartet of new executives. Connected fitness startup Tonal is rumored to be pursuing private funding at a $200M-$300M valuation, a nearly 90% decline from the $1.9B valuation it floated back in September 2022.

Regulatory Developments and Adapting Digital Health Startups

If circumstances weren’t treacherous enough, digital health startups are bracing for impending regulatory changes. In Q1 2023, an acronym soup of federal agencies (FDA, CMS, DEA, FTC) announced preliminary steps and timelines for refining policies across digital health. These revised guidelines have far-reaching impacts, affecting telehealth reimbursement, controlled substance distribution, healthcare service pricing and rebates, and patient data management. Top of mind is the announcement to end the COVID-19 public health emergency (PHE), which is slated to expire on May 11, 2023.

In the realm of telehealth delivery—perhaps the biggest area of healthcare expansion during the pandemic—telemedicine will officially lose its status as an excepted benefit2 and certain federal penalties for HIPAA non-compliance of telehealth platforms will be reinstated. In alignment with PHE’s conclusion, other government bodies are rolling back pandemic-era measures. State agencies are beginning to unwind expanded Medicaid coverage in conjunction with the expiration of a 2020 federal provision requiring continuous enrollment.

States resume disenrollments, anywhere from 5 to 14 million Americans stand to lose Medicaid coverage and associated benefits, with the hardest-hit populations being low-income youth and working individuals without employer-sponsored plan access. In terms of data privacy and security, Congress introduced the Upholding Protections for Health and Online Location Data (UPHOLD) Privacy Act to regulate companies’ use of health data, the FTC settled investigations into BetterHelp and GoodRx with hefty fines, and the FDA enhanced cybersecurity requirements in regulatory applications for medical devices. Finally, on the billing and coding front, CMS issued its 2024 Medicare Advantage Advance Notice to root out aggressive upcoding practices.

What You Should Know:

• Uber Health, Uber’s healthcare arm, today announced same-day prescription delivery on its HIPAA-supported, centralized platform.
• For the first time, those using Uber Health—including healthcare providers and health plans—will be able to manage prescription delivery from any pharmacy in their service area through the same platform they already use to coordinate transportation for patients. This launch enables providers to offer a full suite of care solutions that extend beyond the four walls of a clinic and is designed to improve patient experiences and health outcomes.

Enabling Health Systems to Give Patients Seamless and Direct Access to Prescriptions

Today’s news furthers Uber Health’s mission to optimize how patients access care. The platform allows connectivity to the key services providers require to address patient needs including prescription delivery, stress-free rides, and soon, the delivery of healthy food and over-the-counter medicine for those who need it most—including Medicare Advantage and Medicaid beneficiaries.

When Uber Health launched in 2018, the business focused primarily on streamlining non-emergency medical transportation (NEMT) options, enabling patient populations—especially underserved and vulnerable communities—to get to and from medical appointments. While transportation is an important social determinant of health, it’s only one piece of the patient care puzzle. For example, a patient discharged from a hospital regularly requires a ride home and to follow-up appointments, as well as new prescriptions. Launching prescription delivery powered by ScriptDrop on the Uber Health platform ensures organizations can fulfill their duty of care obligations to patients by arranging direct, same-day delivery of their prescriptions while tracking when they arrive, enabling them to fully “close the loop.”

The tracking of care delivery across multiple disciplines promises a paradigm shift in an industry where providers and health plans could lose sight of patients outside of a provider’s office. Imagine a patient with a chronic kidney disease diagnosis who regularly needs transportation to specialist appointments that result in prescription changes of critical medications. Rather than burdening the patient with homework, Uber Health furthers the patient care team’s ability to arrange these services directly and track that they occurred. Uber Health facilitates critical touchpoints that enable payers and providers to provide maximum quality care at minimum cost.

“At Uber Health, we are building solutions that address lessons we’ve learned from years at healthcare companies operating in value-based care contracts. Too much time has been spent ensuring patients had a ride to their follow-up appointment, had picked up the right prescriptions, or had access to food,” said Caitlin Donovan, Global Head of Uber Health. “That’s why I’m proud to add a scalable prescription delivery solution to our platform that empowers care teams to fully close the loop. From prescription delivery and NEMT today to healthy food and grocery delivery in the coming months, Uber Health remains committed to delivering a more connected care journey through a single, seamless platform.”Powered by an integration with ScriptDrop, prescription deliveries can be facilitated through any pharmacy registered with the NCPDP within delivery coverage areas. Importantly, Uber Health allows for access to delivery coverage areas that include pharmacies dispensing medications covered by the 340B program, helping health plans and providers reach low-income and uninsured patients.

What You Should Know:

– Aledade is continuing its strong momentum today, announcing that Cigna Healthcare Medicare Advantage customers can now receive value-based care from Aledade’s network of independent primary care practices.

– Participating practices can access Aledade’s cutting-edge data analytics, user-friendly guided workflows, and health care policy expertise, as well as integrated care services supported by AledadeCare Solutions.

– This news comes shortly after Aledade announced a 10-year collaboration with Humana, and a partnership with CareFirst Blue Cross and Blue Shield to advance value-based care to more independent physicians. 

What You Should Know:

– PointClickCare Technologies, a healthcare technology platform enabling meaningful collaboration and access to real‐time insights at every stage of the patient healthcare journey, today announced the acquisition of Patient Pattern. Financial terms of the transaction were not disclosed.

– The combination of PointClickCare and Patient Pattern will further the companies’ shared vision of enabling better care and outcomes for high-needs populations and provide care teams with the solutions they need to successfully operate at the top of their license.

Shift to Value-Based Care

The shift to value-based care continues to accelerate each year, especially as providers are increasingly taking on more risk. According to a recent McKinsey and Company study , the number of patients treated within the value-based care landscape could roughly double in the next five years. Institutional Special Needs Plans (I-SNPs), demonstrate the enormous potential of aligned value-based care models.

Patient Pattern Acquisition Impact

Patient Pattern is a leading value-based care EHR and integrated care management platform. Patient Pattern services Medicare Advantage Special Needs Plans, ACO REACH participants, and PACE programs. Practice providers who are transitioning to value-based Care models can manage both traditional fee-for-service and value-based functions in a unified platform.

PointClickCare and Patient Pattern’s combined offerings provide a mechanism to adopt and succeed in risk-bearing arrangements without having to use multiple fragmented solutions. Through this acquisition, PointClickCare will further enable providers to take a comprehensive approach to frailty, ultimately providing better overall care planning.

What You Should Know:

– Signify Health announced a partnership with Cardinal Health, a medical device and pharmaceuticals supplier, to provide in-home medication therapy management to Medicare members.

– In order to provide a more coordinated care experience and help members with their often-complex medication regimens, Signify’s mobile network of 11,000 credentialed clinicians will be able to offer medication management services for health plan members through in-home health evaluations and identify and resolve medication needs of patients via Cardinal Health’s Outcomes™ platform. 

– Using the insights gathered during  in-home evaluations, Signify Health is able to use the OutcomesOne™ platform to identify and resolve the medication therapy management needs of members. The collaboration will initially focus on addressing interventions recommended for Medicare Advantage members of joint clients and may expand into additional services, such as population health programs, and additional clinical interventions.

What You Should Know:

– Apixio, a leading AI platform that powers value-based care launches its new Apicare Post-Visit™ offering, an EHR-integrated intelligent workflow solution for health plans and providers. With the Centers for Medicare & Medicaid Services’ recent Medicare Advantage Risk Adjustment Data Validation Final Rule, healthcare organizations need to have complete diagnosis capture and accurate documentation for reimbursement to ensure compliance.

– The new Post-Visit solution completes Apixio’s Apicare Prospective Suite™, which also includes Apicare Pre-Visit®, an EHR-integrated solution that optimizes the clinical chart prep process by surfacing insights of suspected conditions from structured and unstructured data, as well as Apicare Point-of-Care™, which pushes risk gaps to clinicians within the EHR workflow for risk capture. This comprehensive approach to prospective reviews helps health organizations achieve faster workflows to reduce administrative burden, drive more reliable financial performance, and deliver insights to improve patient outcomes.

– Concurrent reviews are conducted immediately after the patient encounter prior to claims submission to ensure the diagnosis coding is accurate and supported by the patient encounter documentation. Completing these processes manually is an extensive endeavor consequently creating significant backlogs in the administrative processes. This burden contributes to provider-staff abrasion, inaccurate risk capture, and potentially incomplete documentation of patient conditions to support value-based care workflows.Apixio’s Post-Visit solution solves these problems with an AI-driven workflow that mines through encounter data immediately following a patient visit to surface ICDs. Its intelligent work queue prioritizes encounters for review, surfaces high-confidence diagnoses to accept, remove, or add, and allows reviewers to send queries into the EHR workflow for clinical validation. This fully digitized process improves the accuracy and completeness of diagnosis documentation.

Today’s relationship between payers and providers is more fraught than ever. With a history of transactional, often adversarial, fee-for-service contract negotiations, it’s no wonder that the healthcare industry has grown too comfortable pitting payers and providers against each other.

The lack of trust and transparency between the two groups has led to a perceived misalignment of vision. Across the board, the administrative staff has shouldered the brunt of this friction, which in the end affects patient care and revenue growth negatively. A recent study reported that up to 28% of administrative waste could be eliminated each year if payers and providers worked together. 

Both payers and providers have already felt the pinch of clinical staff shortages, but the shared pain points don’t end there. A Kaufman Hall report says that 2022 was the most challenging financial year for U.S. hospitals and health systems since COVID-19, with increased operating costs and a lack of staff resources to treat an increased patient volume. Similarly, payers are under more scrutiny from the Centers for Medicare and Medicaid Services, as more strict audits of Medicare Advantage plans could result in payers repaying billions of dollars. 

Clearly, it’s time to stop framing the payer-provider dynamic as foes to be conquered, and instead, consider the importance and benefits of more collaboration – what could be possible with improved payer-provider relations, and what changes we should make as an industry to help us get there.

Shared Data Views to Bridge the Divide

One of the simplest ways that payers and providers can start bridging the divide is to implement shared data-driven patient practices. 

While the amount of healthcare data is growing exponentially, it tends to be in siloed and disparate places, presenting a significant barrier to usage. For example, payers and providers each use different data sets – payers tend to have historical data driven by claims over a long period of time, while providers tend to have more granular clinical and financial data that updates in real-time.

However, it is not enough to know that informational data silos exist. In a world where faxes still reign supreme and mere “EHR” access is granted through portals – due to lack of interoperability, HIPAA concerns, and more – we must tackle data silos with technology solutions that offer more intuitive, prescriptive, and truly shared data views. 

When payers know what data providers need and vice versa, they can provide each other with what’s necessary to accomplish mutually desired outcomes – a more empathetic approach to data-sharing, if you will, in an environment that each party can equally access, as opposed to proprietary systems. Shared data views, updated in real-time, can also help identify a single source of truth that can serve as the bedrock on which to build trust and eventually payer-provider alliances.

Accelerating Alignment through Advanced Technologies

Once payers and providers establish a foundation of data sharing to lay the groundwork for collaboration, they can implement more advanced technologies. AI or machine learning-driven tools that support the work of both payers and providers can be layered on to accelerate alignment. 

For example, such tools can lessen the burden of utilization management (UM) on administrative staff, a traditionally manual process, that in many ways has become counterintuitive to the very goals UM was designed to accomplish – to ensure appropriate and judicious use of healthcare resources. Specific, but not limited to, UM, payers and providers can leverage predictive analytics within shared, trusted data views to establish agreed-upon thresholds – what is likely to be agreed upon as inpatient versus observation – to automate decision-making. If up to 90% of all services are ultimately approved, we should be using the science of data to work smarter, not harder, to remove unnecessary tasks and administrative waste associated with these processes.

The Business Case is a Clarion Call for Better Tools, Processes

Building and maintaining successful payer-provider alliances are much more than AI technology augmenting criteria-based utilization management solutions, however. Given the current healthcare landscape, as mentioned above with staff and revenue challenges, there is also a clear business case for improvement – and “working together may be the only way forward,” as Kaufman Hall suggests. 

To eliminate the zero-sum game mentality between payers and providers, we must establish new ways for them to approach problems together. And luckily, the tide seems to be turning, with the appetite for improved payer-provider relationships as strong as the need – 92% of provider executives say they desire greater collaboration with payers. 

The healthcare industry must therefore increase awareness and adoption of tools to help deliver on this need, ushering in a new era for payers and providers, where they can be united in their efforts to reduce administrative waste while improving staff productivity and the bottom line, ultimately enhancing the member’s, or patient’s, experience as well. 

About Dr. Heather Bassett

Dr. Heather Bassett has over 20 years’ experience in healthcare and has served as Chief Medical Officer for XSOLISsince January 2013. She leads XSOLIS’ team of physicians and partnered with its data science team to pioneer the Care Level Score(CLS), which combines clinical expertise and data science for a numerical representation indicating the appropriate care status for each patient.

Dr. Bassett earned her Bachelor of Science in biological sciences from Carnegie Mellon University in Pittsburgh, Pennsylvania, and her Doctor of Medicine from the University of Texas Medical Branch in Galveston, Texas, where she worked as a research associate in the field of DNA repair. She undertook her residency in internal medicine at Vanderbilt University Medical Center in Nashville, Tennessee, and worked as a hospitalist at Centennial Medical Center in Nashville for eight years. She is board-certified in Internal Medicine.

What You Should Know:

– Aledade today announced the acquisition of Curia, a leader in value-based care analytics using practical applications of artificial intelligence (AI) to optimize the targeting of patient care and engagement programs.  The acquisition will enhance Aledade’s ability to extract valuable insights from disparate data sources, provide more accurate predictions using past data, and optimize primary care workflows through cutting-edge AI algorithms.

– In addition, the company announced it has added 450 new independent primary care practices in 2023, making it the largest independent primary care network in the country. The company continues to be the largest network of independent primary care in the country, with more than two million patients covered by more than 150 value-based contracts across Medicare, Medicare Advantage, Medicaid and commercial payers.

Curia Background

Curia leverages AI and machine learning to automate the core analytical processes needed to identify risk gaps, predict the likelihood of adverse health outcomes like preventable hospitalizations and optimize the targeting of care and engagement programs. Aledade’s acquisition of Curia follows a successful pilot leveraging Curia’s technology and talented team of data scientists, software engineers and business strategists in the targeting of comprehensive advance care planning (CACP) services to the patients who need them most. Using the predictive algorithm developed by Curia, Aledade was able to identify more than 8,000 patients facing the highest risk for mortality in the next two years and work with primary care practices in its national network to enroll these patients in a CACP facilitation. Aledade is exploring even more use cases that will bring targeted care interventions directly to the patients who need them.

The Centers for Medicare & Medicaid Services (CMS) recently proposed a new rule to advance interoperability and improve the prior authorization (PA) process for Medicare and Medicaid patients. Specifically, the rule stipulates that health plans adopt electronic prior authorization processes, adhere to shorter turnaround times, clearly communicate denial reasons, publish key metrics annually, and implement the Fast Healthcare Interoperability Resources (FHIR) Application Programming Interface (API). The intent of CMS’s rule is to improve transparency, reduce physician burden, and accelerate patient access to care. 

This follows closely on the heels of last year’s legislation, the Improving Seniors’ Timely Access to Care Act, which unanimously passed the House in September, but did not make it to the Senate floor before this year’s Congress convened. The new rule from CMS represents additional progress and includes public feedback from a former iteration of the rule that was proposed in December 2020. Generally viewed as a highly burdensome process, PA is considered necessary by health plans to help ensure their members receive safe, quality, high-value care; however, the process consistently leads to friction with physicians and delays in care for patients.

Historically, efforts to remedy the PA process have focused on automating health plans’ existing processes – as if efficiency was the only missing ingredient in an otherwise sound process. The rule, while designed to help drive greater PA efficiency and transparency, sets a foundation for payers to do much more – including reducing unwarranted care variations and better aligning with value-based care models to more holistic, longitudinal care and driving evidence-based care paths – all of which can lead to better, faster care. 

It’s true that PA is time-consuming and fraught with administrative burdens for physicians and staff – typically requiring faxing and even the mailing of clinical notes. On the health plan side, some employ large call centers to reduce the administrative burden on their staff. A recent AMA survey revealed that physicians and their staff spend an average of 13 hours each week completing PA requests. The survey also found that 93% of physicians say that PA delays patients’ access to necessary medical care, and 82% of physicians report that PA processes can sometimes lead to treatment abandonment. 

Indeed, digitizing PA processes, for example by employing the FHIR API, does accelerate the submission of requests and the ensuing clinical review process. It does not, however, on its own, transform PA into a more valuable tool for care management or for reducing unnecessary variations in care. So, a valuable opportunity for health plans to further improve either quality of care is overlooked. 

While the provisions for the CMS rule would not go into effect until 2026, health plans using manual or partially automated PA processes will need to invest in infrastructure and technology to support this transition well before then. This pivotal moment provides an opportunity for health plans to adopt advanced technologies that not only ensure regulatory compliance but enable more strategic care management. It is time for intelligent utilization management, beginning with prior authorization.

Using artificial intelligence and machine learning, an intelligent prior authorization platform can extract patient-specific data from several sources, including the electronic health record. Armed with the patient’s care history and evidence-based criteria, an intelligent platform can guide physicians toward care choices that are likely to improve patient outcomes. And rather than submitting several disconnected PA requests for one patient, clinicians can get multiple services approved simultaneously – spanning an entire episode and effectively speeding patient access to the most appropriate care.

An intelligent prior authorization platform can easily meet the rule’s requirements for greater automation, more transparency, clearer guidance, and accelerated approvals by utilizing evidence-based clinical criteria that are clearly defined and referenceable for physicians. 

The sole focus of prior authorization should be the patient – better outcomes, better patient experience, and a more clinically appropriate care path. Electronic PA is surely a good starting point, but it is not enough. To have a significant impact on the cost and quality of care, healthcare should adopt intelligent technology that gives providers meaningful support to help achieve the fastest and best possible outcomes for patients.

About Alina M. Czekai, MPH

Alina M. Czekai, MPH, is the Vice President of Strategic Partnerships at Cohere Health, a collaborative utilization management technology vendor. Prior to joining Cohere, she was a senior advisor to Administrator Seema Verma at the Centers for Medicare & Medicaid Services. LinkedIn – https://www.linkedin.com/in/alinaczekai/. 

What You Should Know:

 Mighty Health, the first all-in-one daily health program designed for adults ages 50 and up, today announced $7.6M in new financing co-led by Will Ventures and GFT Ventures.

– Mighty Health has built the modern home for healthy living for 50 on up, offering aging adults access to personalized and holistic health guidance through joint-friendly workouts, chronic condition-specific programs, custom nutrition plans, and 1-on-1 health coaching.  

The home for healthy living for 50 on up

Founded in 2019 by tech entrepreneurs James Li and Felipe Lopes and Columbia University Medical Center Vice Chair of Research Dr. Bernard Chang, Mighty Health is on a mission to provide people entering the second half of life with tools and resources to reverse chronic disease and pain and feel stronger every day. The Mighty Health board of advisors includes New York Times bestselling author of Originals and behavior change expert Adam Grant, Care.com founder Sheila Marcelo, and leading cardiologists, geriatric specialists, and other healthcare experts. Mighty Health is the the first all-in-one daily health program designed for adults ages 50 and up—covers more than 9 million Americans nationwide through partnerships with leading Medicare Advantage and commercial health plans. The app has supported more than 200,000 individuals to date, with exciting plans for expansion and new offerings.

Unlike fitness supplemental benefits traditionally offered by health plans, Mighty Health provides holistic health guidance beyond fitness, paired with human accountability and a fun, vibrant community. In addition to more than 250 low-impact workouts, Mighty Health members enjoy a comprehensive library of personalized grocery lists and recipe recommendations, guidance on relevant health topics including sleep and arthritis, live virtual events such as cooking classes, meditation sessions, and doctor Q&As, and their own certified health coach. Coaches text with members on a near-daily basis to check in on progress, provide encouragement and accountability, and address questions or needs that arise.

Availability

Mighty Health is available directly to consumers and fully covered as a free health benefit by Medicare Advantage and commercial health plans for over 9 million lives nationwide, including through partnerships with Gympass, Forma, and top national health plans. This next phase of growth will see Mighty Health rapidly expand their partnership footprint and launch multiple in-depth chronic disease programs, solidifying the platform’s place as a centralized hub for not only fitness, nutrition and general wellness, but also the most common concerns and conditions as an aging adult.

What You Should Know:

– IllumiCare, a pioneer in point-of-care healthcare information technology, today released a new report detailing how increased data transparency between health plans and providers on care and coding gaps results in higher compliance, process improvement, and positive behavior changes among network providers. 

– The report demonstrates, across multiple plans, that placing previously unavailable yet actionable information on quality gaps, HCC (Hierarchical Condition Categories) capture, HRA completion and other initiatives, within the provider’s workflow, is effective in closing more gaps.

Improving Quality of Care Via Increasing Data Transparency

Over the seven-month period, a large Medicare Advantage plan used the Ribbon to focus on quality measures and saw a 342% net increase in users achieving a 4+ star rating, outpacing their peers. The Ribbon users went from seven to 31% achieving 4+ stars, while the non-users went from 10% to 20%. From a risk capture perspective, another plan used the platform to observe and increase HCC capture, finding the process of coding more manageable and enforceable, resulting in an increase of 25% in recapture rates. 

IllumiCare’s Smart Ribbon is an EMR-agnostic platform of clinical apps that requires no separate login, patient lookup or EMR integration. The platform places care and coding requirements and information from the plan conveniently in front of primary care physicians (PCPs) during their normal workflow. It “nudges” them in their workflow as to any care and coding gaps that may exist for the patient, so they can “close the loop.”

The report demonstrates the advantage of making a plan’s gaps data more transparent to the provider at the point-of-care, while also making the provider’s interactions with that data transparent to the plan. This two-sided transparency creates an enforcement loop that eliminates the majority of a practice’s reasoning for not moving the needle in process efficiency. 

“Too many solutions are only focused on delivering the data, but that’s just the start. The most compelling insight from this data is the clear opportunity for behavior change and how plans can work alongside providers to enable it long-term,” said G.T. LaBorde, CEO of IllumiCare. “This opportunity to enact change through a complete feedback loop has not existed before. The provider has clarity on all care needs and the health plan knows who uses the program, when they use it and what they do with it. This is invaluable to improving care for members across networks.”

Nate Maslak, the co-founder/CEO of Ribbon Health

Price Transparency: In 2022, we saw CMS’s Transparency in Coverage rule go into effect, requiring non-hospital entities like health plans and providers to publish publicly available rates for care. In 2023, we’ll see this price transparency data become more mainstream as it finally makes its way into the hands of patients, empowering them to find the best care for them, reevaluate their care choices, and shop around for the best possible care options. Healthcare enterprises will invest in technology and infrastructure to manage this data and interpret it to be more accessible for their users.

BJ Schaknowski, CEO of symplr

In the coming year, the greater economy’s financial concerns are reflected in the healthcare industry. Budgets will remain stretched as decision-makers navigate rising inflation, diminishing reimbursements, and increased supply chain issues all while addressing staffing and burnout concerns. Increasingly, stakeholders will need to prioritize system interoperability and cost-optimizing solutions that leverage data-driven insights. Organizations should expect financial pressures to drive decision-making in the new year.

Russ Thomas, CEO of Availity

In 2023, mounting economic pressures mean revenue cycle leaders will further expand the use of AI and RPA technology to automate and streamline workflows, going beyond authorization and claim status processes commonly seen today. Claim corrections, posting functions, appeal processes, and patient engagement are just a few areas where AI can identify actions to automate with RPA technology. In addition to focusing on operational efficiencies, healthcare revenue cycle professionals will need to develop new skill sets to monitor and manage these technologies to identify and prioritize activities. While efficiency is always a priority for revenue cycle leaders, it’s becoming increasingly critical in today’s market.

Siva Namasivayam, co-founder and CEO of Cohere Health

The adoption of electronic prior authorization is long overdue, as our current processes are not sustainable. Between federal legislation and CMS’ proposed rules impacting the prior authorization process, health plans will need to adopt technologies that not only comply with the new federal regulations but also enable more strategic, proactive care management. As one of the first data signals of planned healthcare encounters, prior authorization is invaluable as a tool to hasten patient access to high-value care. Intelligent prior authorization solutions will provide the transparency and automation needed to align patients, physicians, and health plans on individualized care plans that rely on evidence-based guidelines to reduce variations in care and improve outcomes.

Lynn Carroll, COO of HSBlox

We will see increased development of programs that align global reimbursement with patient-specific episodic models.  Alternative Payment Models for global reimbursement will incorporate patient-specific sub-capitation components, such as specialty carve-outs, episodes of care, and bundled payments.

Patty Hayward, VP of Strategy for Healthcare & Life Sciences at Talkdesk

Healthcare is in an inequitable situation where payers are experiencing double-digit growth and high profits while many providers are reporting record operating losses. The loss of government health emergency funding will only make this worse. This is not sustainable, and I predict it will lead to consolidation in the provider space. One of the bigger impacts will be providers embracing automation and other technology tools that can reduce operating expenses. Automation also can help providers overcome the severe shortage of healthcare workers, particularly in key non-clinical roles like contact center staff.

Kimberly Hartsfield, Executive Vice President, Growth Enablement at VisiQuate

As healthcare organizations are still struggling with data visibility across their revenue cycle operations, the internal debate of build v buy continues.  Many leaders experience “sticker shock” with vendor proposals while failing to consider the actual cost of internal development, lack of resources and ongoing maintenance/support.  There is a time and place to embrace vendor technology.  The data management issues surrounding revenue cycle management operations are not a tomorrow problem.  Finding vendor partners with deep expertise and quantified success saves both time and money while eliminating administrative waste in healthcare operations. In 2023, speed to value is the name of the game.

Michael Stearns, MD, Specialized Consulting Director – Medical Informatics, Health Language

Risk adjustment comes under the microscope: Medicare Advantage Organizations (MAOs) will see increased regulatory pressure in 2023 due to the cost of the program exceeding traditional Medicare and concerns over adequate documentation of reported conditions. Recent MAO audit reports published by the Office of the Inspector General of HHS suggest an increased focus on the adequacy of supporting documentation for reported diagnoses. MAOs will need to carefully review medical records to ensure there is documentation of evaluation and management of all reported conditions and increasingly turn to clinically tuned technology, such as natural language processing, to streamline the process with accuracy to ensure compliance.

Ryan Younger, VP of Marketing, Virtua Health

Finances will continue to be top-of-mind for health systems in 2023, particularly if we enter a defined economic downturn because consumers will tighten their belts across the board; healthcare is no exception. As consumers look for areas to cut unnecessary spending, they will seek out less services proactively. Health systems that collaborate effectively with physicians to offer a full spectrum of services will have a leg up because they provide more options and lower-cost settings.