What You Should Know: 

– Amwell and Leidos have been awarded a “next-generation contract” by the U.S. Defense Health Agency (DHA) to deliver a hybrid care platform to power the DHA’s Digital First transformation. This initial 22-month contract is valued at up to $180M; the project will start at five initial sites followed by a phased enterprise-wide rollout.  

– While this task order is for the first phase of the program, the DHA Digital First program will support the entire MHS community of users, which includes 9.6 million active-duty service members, family members, retirees, and health professionals across the continuum of care.  

DHA Digital First Inititiave

Under this task order, the Leidos Partnership for Defense Health (LPDH) will deliver Amwell ConvergeTM, a comprehensive hybrid care enablement platform designed to power the full continuum of care using digital, virtual and automated modalities, and replace the Military Health System (MHS) Video Connect solution. It will start at five initial sites followed by a phased enterprise roll-out. Also included in the contract are a broad spectrum of Amwell automated care programs that have a proven track record of helping deliver better health outcomes, including multiple behavioral health and integrated core telehealth solutions.

The DHA’s Digital First initiative brings new capabilities and enablement to MHS GENESIS, an advanced electronic health record (EHR) and healthcare system solution that supports military and Veteran healthcare initiatives. The Converge platform has deep integration assets and a simple yet powerful user experience that enables efficient and quality hybrid care delivery. The platform is already embedded into existing clinical workflows that care teams rely on, including those within the core EHR that powers MHS GENESIS. Together, Amwell and LPDH will enable the DHA to leverage the benefits of hybrid care, improve access to primary and behavioral health care, and ultimately improve outcomes for the MHS community.

The DHA supports national security and ensures our nation’s military teams are ready to deploy. Seeking to leverage innovation and best practices from the commercial sector, the DHA conducted a thorough evaluation of the Amwell solution.

“Digital First addresses DHA’s goal of better outcomes, new processes, innovation and increased standardization based on evidence,” said Jason McCarthy, Leidos senior vice president, Military and Veterans Health Solutions. “As part of our overall MHS GENESIS effort to enhance patient experience, we, along with Amwell, are looking forward to providing near real-time, self-service support and hybrid care options for our customer and those whom they serve.”

When it comes to the Great Resignation, forget office workers – the real wave of resignation is coming from nurses. For many months post-COVID, nearly every headline, or so it seemed, was about office employees, their career paths, and the return to the office. What was underreported then – and continues to be – is that the Great Resignation came in full force for nurses. 

The dynamics in healthcare are always complicated: Costs are going up, margins and reimbursements are shrinking, and there are clinical shortages everywhere (with no hint of it letting up anytime soon). Our U.S. healthcare system is placing a very heavy burden on nurses who are being driven to the brink, often leaving the field altogether.

Nurses provide critical care for all of us. They’re the lifeblood of our healthcare system, but burnout continues to push them out, creating an untenable situation in communities across the country. Here are four tips on how to keep nurses in the field. 

1. Offer more than a “thank you” 

Nursing is more than a job – it’s a calling. While most nurses go into the profession to make a difference, they’re leaving in droves, which has been widely reported. They’re overworked, underappreciated, and underpaid. Nurses often work under unsafe staffing ratios as some health systems cut corners to keep their budgets balanced or struggle to find experienced clinicians to fill shortages.  

So much has been written about the power and flexibility technology can offer employees in dozens of industries, especially those in service-related ones. In today’s climate with solutions like conference services, virtual private networks, and SaaS-based productivity suites, workers are able to work from almost anywhere they want, so why not nurses too? 

Technology has supercharged travel nursing by making it easier than ever to find desirable positions. And, perhaps the most obvious benefit is the ability to take a well-compensated assignment, and – even more importantly – one that they want and for which they’re a good fit. 

2. Recognize that self-determination drives satisfaction

Travel clinicians can help restore job satisfaction among clinicians and help boost retention and productivity for healthcare facilities by ensuring units are fully staffed and patient-to-staff ratios remain manageable. Recent survey data shows that more than three out of four (76%) travel clinicians report satisfaction with their most recent placement. So much so that 83% of them would recommend the profession to a friend. 

The reported high rates of satisfaction can be attributed to a number of factors, including empowering clinicians by giving them more control over their own career journeys with a better sense of flexibility and choice. Travel clinicians can select assignments that appeal directly to what they want at that stage in their careers, whether it is the ability to learn new skills, maximize their existing expertise, or create a better work-life balance. They can also avoid elements like unmanageable patient-to-staff ratios, excessively long shits, and hospital politics. Knowing there is always a light at the end of the proverbial tunnel, coupled with the ability to build in time for rest and recuperation, can have a very positive impact on a professional’s mindset and happiness.

3. Hone in on specificity and skills mapping 

In a field as specialized as nursing, traditional recruitment methods won’t cut it anymore. Nurses know what their expertise is, where their passions lie, and what jobs in which they belong. For far too long, travel recruiters have been selling jobs to nurses without putting much thought into whether a particular position aligns with that nurse’s background. Healthcare facilities that want to make meaningful improvements for their staff need to hire people, and the best way to do that today is with technology. 

Technology, such as automated staffing platforms, allows job-seeking nurses to regain control over their careers. Rather than trying to force a NICU nurse into a med-surg job, these recruitment tools give them the opportunity to self-review job postings and their required skill sets to determine which are a match. They allow nurses to operate at the top of their licenses and thrive there. Medical workers utilizing staffing platforms are typically only going to apply for positions they really want. Accepting an assignment they know fits their interests and expertise immediately sets them up for success and inherently lowers their chance of burning out on the job, or canceling prior to the set start date. 

4. Reimagine education

The demand nationwide is partially due to the fact that graduation numbers at many nursing schools have slowed to a trickle. There are not enough educators, which means those in school are unable to complete their training, increasing the waitlists to even get into classes. 

Some states, like Minnesota, are tackling this problem head-on. The University of Minnesota and Minnesota State University formed the Coalition for Nursing Excellence and Equity in the hopes of attracting more students to the field without increasing the costs of education. By attempting to mitigate any racial, systemic, or financial barriers that may prevent minority caregivers from pursuing careers in nursing, the coalition hopes to move nursing students forward while addressing the worsening staffing shortage in hospitals and clinics.

Helping nurses get trained and certified is hugely important, but a new generation entering the workforce means new expectations, values, and work preferences, particularly concerning technology. In today’s nursing schools, technology is ubiquitous. Hardware such as tablets and medical software are central to how students complete their courses. Not only that, but today’s nursing students – regardless of age – use technology in every aspect of their lives. And after they graduate, they prefer to use technology like automated staffing platforms. 

We can’t afford not to act

With data forecasting that by 2030 4.7 million nurses worldwide will retire, leaving a deficit of 900,000 RNs in the United States alone, this paints a grim picture for our healthcare system, which cannot function without nurses. This means everyone in need of care – each and every one of us – will likely spend more time in waiting rooms than with the clinician. It also means longer wait times for procedures, hospital beds, and even emergency care. 

For healthcare facilities, the shortage impacts the bottom line. Without the personnel in place to provide care and perform critical surgeries – a hospital’s primary source of revenue – facilities will not be able to sustain themselves, leaving many communities without healthcare and the ability to receive medical treatment in their own region. 

Fair and competitive compensation, self-determination, personal agency and skills mapping, and educational opportunities are four critical ways to shift energy and positivity into healthcare, address nursing burnout, and arrest the Great Resignation among our most valuable professionals. 

After all, based on what they offer us all, nurses deserve so much better than they’ve been given, and it is within our power to provide that. 

About Kim Howard

Kim Howard, is chief client officer at Nomad Health. She brings more than 25 years of staffing industry experience, with 18 years focused entirely on the healthcare market. With prior experience at AMN and Nursefinders, Kim is passionate about providing clinicians with the tools, information, and support they need so they can find the most rewarding assignments with as little effort as possible, allowing them to do what they love the most – focus on their patients. 

What You Should Know:

• Today Innovaccer Inc. announced that Curana Health, an innovative, fast-growing healthcare organization on a mission to improve the health, happiness, and dignity of senior living residents, is expanding its partnership with Innovaccer to meet strong market demand for its services, and to support the expansion of its value-based programs for high-risk populations nationwide.
• Last year Innovaccer announced that Curana Health had chosen Innovaccer’s Best in KLAS data and analytics platform, care management solution, and point-of-care physician engagement solution to create a new technology platform purpose-built for senior living communities. Curana Health is a provider-led, primary and post-acute organization, that works with Skilled Nursing Facilities, Assisted Living Communities, Memory Care Communities, and Life Plan Communities / Continuing Care Retirement Communities

Expanding Access to Value-Based Care Across the Nation

Since then, Curana has undergone significant growth, expanding its presence to 30 states and establishing partnerships with over 1,100 senior living communities, including various types of care facilities such as skilled nursing facilities, assisted living, memory care, life plan communities, and continuing care retirement communities. This expansion has provided over 750 healthcare providers with the opportunity to excel in value-based care delivery. Curana has achieved this through a provider-led medical group, Medicare Advantage health plans, a Medicare Shared Savings Program (MSSP), and a newly formed ACO REACH organization. Notably, Curana’s MSSP, known as Elite Patient Care ACO, performed exceptionally well in its inaugural year, ranking in the top 1% of all ACOs. It achieved impressive gross savings of $2,235 per beneficiary per year, marking the highest per beneficiary per year savings for a first-year MSSP ACO since 2012.

“We’re committed to technology innovation that improves the experience, communication, and clinical decision-making of our networks’ care teams to enhance health outcomes; and support the performance of value-based contracts among one of the industry’s highest risk populations,” said Todd Tyler, CIO of Curana Health. “We chose the Innovaccer platform so we could work with not only our own EHR, but with any EHR or systems we need to integrate to extend the Innovaccer technology platform. Innovaccer is enabling us to scale population health management for more and more partners in our footprint, and to support innovative VBC models, such as our new ACO REACH program. With the Innovaccer platform, we can unify patient records, share care plans, and maintain continuity of care across all care settings and value-based contracts as fast as we grow.”

Innovaccer and Curana are joining forces to enhance care access, quality, and outcomes for high-risk populations. They’ll achieve this by consolidating patient records across various systems, automating care management, enabling remote patient monitoring, addressing social determinants of health, identifying at-risk patients with AI analytics, closing care gaps, enhancing clinician experience, and more.

We reached out to six digital health executives for their key takeaways and reflections from attending the recent HLTH23 conference.

Patches Seely MBA, BSN, RN, Executive Vice President of Clinical Solutions, Carenet Health

“The energy of everyone I connected with was very encouraging. These are difficult times in healthcare, but I often heard people saying, “I’m not sure how exactly we will partner, but let’s figure it out.” The collaborative atmosphere spurred productive conversations about combining consumer and clinical data to address social determinants of health and the optimization of at-home care. Change can be made to address social determinants of health with policy engagement, risk-based models, and the use of innovation labs. The home is becoming the new clinic, ED, or hospital, and roles throughout the healthcare system are evolving to accommodate this shift.”

Rhonda Gibler, Chief Sales Officer, Carenet Health

“The conference included discussions on many important, relevant topics in the industry today. I gained valuable insight into ways generative AI applications can reduce the strain many individuals in the healthcare system are experiencing. With the combination of AI technologies and available domain experts, focus will be placed on patients and tasks best performed with human capital. This is an important challenge to address as we balance tech-enabled solutions and staffing strains throughout the healthcare ecosystem.”

Ted Ferrin, Co-founder and CEO of Rivet

Healthcare is not immortal — that was my overriding takeaway from HLTH. There has been real hesitance around funding, as well as M&A activities, due to economic instability, the hit in valuations and momentum to the broader tech startup world, and there have been some very publicly-failed health tech startups that are giving people reason to measure twice and cut once before putting any faith behind something new. My colleagues in the vendor community should take note that both provider organizations and potential funders are looking for the same thing: exquisite metrics. Now is the time to deliver undeniable value to your customers. Our industry will continue to see market conditions that require substance and only companies that can demonstrate it for their customers are going to win.

Jon Kimerle, Global Healthcare Strategic Alliances, Pure Storage

“Health tech startups and early-stage companies far outnumbered enterprise healthcare organizations and payers at this year’s HLTH conference, pushing new and innovative AI-powered technologies and services to the forefront of discussion. AI has long been a buzzword in the industry. However, the global pandemic continues to serve as a catalyst to driving transformation with advanced technologies, intensifying the urgency for healthcare organizations to deliver quality care, at scale. What will be most important moving forward is ensuring that the healthcare industry strikes the complex balance between investing in emerging and advanced technology that will positively impact patient outcomes, while setting up a foundation (data storage infrastructure) on which future initiatives – including advanced AI use cases – can thrive. With thoughtful investments, organizations can keep vital systems running efficiently while accelerating their ability to keep pace with digital transformation.”

Diana Zuskov, Associate Vice President, Healthcare Strategy, LexisNexis

“The overall expansion of the conference and the addition of many first-time attendees was a pleasant surprise. It was exciting to see some non-traditional healthcare companies joining the health innovation ecosystem. I heard lots of discussion on retail health and how that model is critical to transforming access. I was encouraged to see providers and solution vendors exploring how to bridge together the entire digital experience, from identity verification to identity management, to ensure all the data and touch points are efficiently mapped to the consumer.” 

Andrew Norden, MD, MPH, MBA, Chief Medical Officer, OncoHealth

“I was really pleased to see lots of oncology topics on the agenda, including early detection strategies, cancer care approaches among employers, and the new CancerX initiative. One session I found particularly interesting included Anabella Aspiras, Assistant Director of the White House Cancer Moonshot Engagement. She reminded attendees that improving access to cancer navigation is a key component of the Moonshot agenda, and she spoke to the importance of improving not just the outcomes of cancer but also the experience of cancer care, which I too feel strongly about. Generative AI also came up in virtually every session I attended, with many speakers focusing on its enormous potential to help in many different aspects of healthcare.”

What You Should Know: 

– DaVita Inc. and Google Cloud are teaming up to create a new clinical operating system that sets a foundation for streamlined kidney care for more than 200,000 DaVita patients.

– Built on Google Cloud infrastructure and utilizing AI and analytics tools co-developed by the two companies, DaVita’s Center Without Walls (CWOW) is now live across the organization’s 2,700+ dialysis centers nationwide. 

– With the deployment, DaVita has moved from a decentralized clinical documentation system to a unified platform that leverages data from more than 30 million dialysis treatments per year to generate insights designed to help improve clinical outcomes.

Customized Clinical Operating System Designed to Transform Kidney Care

CKD affects more than 1 in 7 adults in the United States, an estimated 37 million Americans, and as many as 9 in 10 adults who have CKD are not aware they have the disease2. Currently, an estimated 50% of people diagnosed with kidney failure “crash” into dialysis—starting treatment without warning in an emergency situation3. Crashing not only causes physical and emotional stress for patients but also it costs, on average, an additional $53,000 per patient in the first year of dialysis treatment.

By creating CWOW using Google Cloud, DaVita has built a foundational platform that will enable seamless data sharing and increase collaboration between the company’s physician partners, hospitals, and internal care teams. Ultimately, the platform is designed to support DaVita’s mission to provide integrated kidney care that helps improve patient quality of life, and lower the cost of care. To effectively leverage this data, DaVita built CWOW on Cloud Spanner for scalable database management, BigQuery for analytics, and Vertex AI for AI and machine learning.

“Google is the right choice for DaVita – not only from a technical perspective, but also from a collaboration standpoint,” said Alan Cullop, DaVita’s Chief Information Officer. “Our vision for CWOW required a flexible collaborator that would be willing to iterate as we worked to address the unique needs of DaVita and kidney care. From early-stage architecture and infrastructure conversations, to AI, analytics and IT security, Google has added significant value every step of the way, and we look forward to the next stage of innovation as we continue to enhance the CWOW platform.”

In May 2022, a California doctor was sentenced to nearly eight years in prison for his involvement in a $12 million Medicare fraud scheme. His crime: performing unnecessary vein ablation procedures on patients, and using incorrect billing codes to receive larger reimbursements. He received $4.5 million in reimbursements from Medicare over a three-year period.

Compared to this example, most instances of “upcoding” and “overcoding” are not as malevolent or expensive. But even an innocent mistake can cause well-intentioned hospitals and health systems to attract attention from federal auditors, and result in stiff penalties for physicians and those who input the wrong billing codes.

Proper medical coding is crucial to accurately reflect the complexity and intensity of any services rendered. Physicians must stay updated on current coding guidelines and ensure that the codes selected reflect the true nature of the patient encounter. This is especially true in a healthcare industry ravaged by layoffs, where every line item is scrutinized and every budget is tight. 

As hospitals and health systems merge, consolidate, and find other ways to reduce operating expenses, having a dedicated team of coders offers critical oversight. They’re often the last line of defense between logging the correct code and a mistake that costs a provider millions of dollars.

Here are 12 best practices for avoiding a costly coding mistake:

1. Code accurately: Physicians should avoid both upcoding (billing for a higher level of service than performed) and downcoding (billing for a lower level of service). Coding should accurately reflect the medical necessity and complexity of each visit. 
2. Accurate Documentation: Complete and accurate medical documentation is essential for justifying the services provided. Clear, detailed, and comprehensive records support appropriate coding and billing, ensuring that services are reimbursed at the appropriate level.
3. Modifier Utilization: Correct use of modifiers can clarify specific circumstances that may affect reimbursement. For example, modifiers can indicate if a service was provided on the same day as a procedure, if a service was discontinued, or if multiple procedures were performed.
4. Medical Necessity: Demonstrating medical necessity is crucial to secure reimbursement. Physicians should clearly document the reasons why a particular service was necessary for the patient’s condition, linking the diagnosis to the treatment provided.
5. Utilization Reviews: Regularly reviewing utilization patterns can help identify opportunities to improve efficiency without compromising patient care. This can involve analyzing patterns of referrals, tests, and treatments to ensure they align with evidence-based guidelines.
6. Negotiate with Payers: Effective negotiation with insurance payers can lead to more favorable reimbursement rates. Physicians should emphasize their value in terms of patient outcomes, quality of care, and cost-effectiveness.
7. Value-Based Care Initiatives: Participating in value-based care models and accountable care organizations can lead to increased reimbursement based on improved patient outcomes and cost savings.
8. Minimize Denials and Appeals: Preventing denials through proper documentation and coding reduces the need for appeals, saving time and resources. When appealing denials, ensure that the appeal includes all necessary information and supporting documentation.
9. Patient Collections: Efficient patient billing and collections processes can improve cash flow. Clear communication about patient financial responsibilities and available payment options can lead to fewer outstanding balances.
10. Continuous Education: Staying informed about changes in healthcare regulations, coding guidelines, and reimbursement policies is essential to adapt to evolving requirements and opportunities.
11. Utilize Technology: Electronic health records (EHR) systems and practice management software can streamline billing processes, improve accuracy, and reduce administrative burdens.
12. Audit Readiness: Maintain records and documentation in a way that ensures readiness for audits. Compliance with regulations and guidelines is crucial to avoid penalties and loss of reimbursement.

When both human and financial resources disappear, in-house coders might face an increasing number of responsibilities that strain their ability to perform the basic, money-saving essentials of their job. It might be wise to outsource to an organization that focuses only on medical coding. These remote teams come with less overhead costs and lack the burden of having to acclimate to other aspects of a hospital’s functions. They can focus their professional development on staying current with coding and coding alone.

Outsourcing is often standard practice for independent physicians, who sometimes do procedures in a health care system but can’t use that system’s coders. Simply outsourcing all their coding becomes the more efficient choice.

Whether outsourcing or in-sourcing, staying current with the rules and regulations of coding is essential to a hospital or health system’s financial health. Physicians and their staff must regularly update their coding knowledge to stay in line with the latest guidelines. This prevents errors and helps accurately represent services provided. 

Although time and money are in short supply for nearly all healthcare professionals in 2023, taking resources away from coding can easily cost more money than it saves.

About Hilton M Hudson

Hilton M Hudson, MD, FACS, is a board-certified cardiothoracic surgeon and the Chief of Cardiothoracic Surgery at Franciscan’s Michigan City and Olympia Fields health systems. He is also the CEO of HPC International (HPC), the leading educational purchased services supplier for healthcare, corporations and academic institutions.

What You Should Know: 

– Waymark, a San Francisco, CA-based Medicaid provider enablement company raises $42M in new financing to scale technology-enabled, community-based care for primary care providers and their patients enrolled in Medicaid programs. The round was led by Lux Capital and CVS Health Ventures joins as a new investor. 

– Existing investors Andreessen Horowitz (a16z) and New Enterprise Associates (NEA) also participated in the round. The investment consists of $22M in equity capital and a $20M line of credit, bringing Waymark’s total capital raised to date to $87M.

– Waymark plans to use its new investment to continue improving healthcare access and outcomes for people enrolled in Medicaid programs. 

Better Care Starts with Community

Patients receiving Medicaid benefits often experience challenges accessing care, prescriptions, and social support like housing and food. Waymark hires, trains, and deploys local teams of community health workers, pharmacists, therapists and care coordinators to work directly with primary care practices – at no cost to the practice – and address gaps in care for their patients enrolled in Medicaid. The company’s local teams are supported by Waymark Signal™, a proprietary machine learning technology that has shown industry-leading performance in identifying “rising risk” populations, or patients at risk of avoidable emergency room (ER) and hospital utilization, and helps to direct Waymark teams to the best evidence-based intervention to meet patient goals. The technology is integrated into a care management software built by Waymark specifically for community-based teams, and incorporates data from multiple sources (e.g., local ERs, primary care practices, social services databases, and health plan data) to engage patients who are traditionally hard to reach.

Waymark enters into risk-based contracts with Medicaid MCOs to deliver community-based care for their rising risk populations and transition primary care practices to value-based arrangements. By building a new community health workforce to support primary care providers (PCPs) – paid for through value-based arrangements with MCOs – Waymark seeks to increase the capacity of its healthcare delivery system and align payment incentives to enable whole-person care.

Market Footprint

Waymark is currently supporting approximately 50,000 people enrolled in Medicaid across both Washington state and Virginia. Since launching in January 2023, the company has secured partnerships with several large health systems, a federally qualified health center (FQHC), and independent practices across both markets. Through its evidence-based care pathways, Waymark has shown promising early improvements in quality scores and clinical outcomes – including reduced non-emergent emergency department (ED) visits and hospitalizations.

“We created Waymark because the evidence of what works to improve Medicaid outcomes exists, but the operational capacity, technology and funding is insufficient to scale to the level of need that exists in communities across the country,” said Dr. Rajaie Batniji, co-founder and CEO of Waymark. “This new financing will allow us to continue hiring and training a new community health workforce, expand PCP capacity, and ultimately deliver on our charter to improve access and quality of care for people receiving Medicaid.”

What You Should Know: 

– HIMSS announced it has appointed Elizabeth Slater Jasper as general counsel, and Anne Tuzik as its new chief financial officer.  

– Jasper comes to HIMSS after serving for 14 years as the chief legal officer, general counsel and corporate secretary for the National Service Office for Nurse-Family Partnership and Child First, an organization that oversees the national replication of maternal, infant and mental health evidence-based programs. 

– Tuzik comes to HIMSS with a focus on both the strategic and operational aspects of financial management while also nurturing a collaborative work environment.  

As a result of the Families First Coronavirus Response Act (FFCRA), Medicaid programs were required to keep citizens continuously enrolled through the COVID-19 public health emergency (PHE). These continuous enrollments ended on March 31, 2023, resulting in what many call the unwinding of Medicaid. 

In June, the Kaiser Family Foundation (KFF) estimated that between 8 million and 24 million people will lose Medicaid coverage during the unwinding of the continuous enrollment provision. The unwinding of Medicaid has become one of the most significant challenges facing state health agencies. 

The Medicaid redetermination process has become mired in procedural challenges during the renewal process, resulting in CMS pausing Medicaid redeterminations in six states. 

In August, CMS also sent a letter to Medicaid directors in all 50 states that evaluated performance on Medicaid call center wait times, call abandonment rates, rates of procedural terminations, and average wait times for applications to be approved. Overall CMS found that 36 states were falling short on meeting the regularity requirements. 

State and local HHS agencies are clearly in the midst of a public health emergency and are finding themselves challenged with processing Medicaid redeterminations at record levels as they resume regular eligibility operations following the end of the Medicaid continuous enrollment condition. 

In addition, many of these agencies are dealing with eligibility and enrollment systems that have been in place for 10 years, or even longer. As a result, these systems are hitting “legacy” classification, and lack modern features to keep up with the current Medicaid redeterminations challenge. 

With the immense ebb and flow of eligibility applications and redeterminations, it is clear that data is key to overcoming this challenge. On top of this, an astounding level of data is increasing every day, along with the demand to leverage this data to meet citizens’ needs.

Automating Legacy Systems 

Fortunately, state health agencies can address these challenges by automating legacy data systems without needing to invest in full IT modernization. 

Legacy systems are essentially mission-critical systems that contain custom code and business processes designed to serve citizens. Part of the challenge is the lack of automation to deal with high volumes of eligibility redeterminations and disenrollments while ensuring coverage continuity for eligible members.

It is possible to create a path to accessing and engaging with data on legacy systems to break down data silos while enhancing overall processes. By combining these modernizing citizen-focused interfaces, agencies can streamline the Medicaid reenrollments, while reducing errors. 

For example, process mining can help agencies pinpoint processes for improvement and allow simulation of the new processes. These types of solutions can run on top of an eligibility and enrollment existing process engine, providing insights into bottlenecks or outliers.

These solutions also offer easy-to-use interfaces that can help business analysts visualize areas of improvement. New processes can also be simulated before going into production for testing desired outcomes and adjusting as necessary.

Many states are also exploring moving their eligibility and enrollment systems to the cloud, which offers new ways to integrate data more effectively to meet citizen needs.  

This transition can be made seamlessly by quickly integrating applications in the cloud, while also offering end-to-end monitoring to follow the complete flow of transactions across multiple applications. As a result, users can easily visualize integration processes and simulate to-be scenarios to assess impact. 

Regardless of the complexity of the data, common integration scenario templates can provide a quick start to integration development. In addition, key solutions allow agencies to pull data from any source across the HHS landscape, which can include data warehouses or legacy mainframes into one common picture. 

By providing an updated visual interface through a range of pre-built connectors, agencies can easily ingest, transform, and deliver data to the desired destinations. This enables them to detect patterns, anomalies, and trends in real time, which can be used for predictive analytics or immediate decision-making around the redeterminations issue. 

The unwinding of Medicaid is presenting a significant challenge for states, as well as for citizens who have relied on receiving this critical healthcare coverage.  Fortunately, updating the manner in which we engage with legacy systems, and better leveraging the data housed in those legacy systems, provides a path for agencies to ensure that citizens don’t lose coverage due to administrative and procedural issues. 

About Chris Oskuie

Chris Oskuie is the Vice President, State & Local Government and Education Sales at Software AG Government Solutions.  Chris has more than 20 years of experience working with Federal and State Government programs. For the past four years, Chris has led a team of experts that helps government agencies modernize how citizens and state employees engage with and access legacy systems through data and event-based integration.

What You Should Know: 

Amazon Web Services and Inovalon announced a collaboration to develop AI and ML-based solutions for healthcare organizations to improve patient outcomes and cost-savings. 

– The collaborated capabilities are being developed for multiple applications across the broader Inovalon ONE® Platform, the Company’s SaaS-based software platform supporting more than 20,000 customer organizations across the healthcare ecosystem. The initial offerings will focus on risk adjustment, with a particular emphasis on developing natural language processing (NLP) tools to improve risk score accuracy for health plans.  

Advanced AI/ML Together with Large Training Datasets

Health plans primarily depend upon medical documentation and medical claims to determine the disease burden, or risk score, of the members of their managed populations. This risk score is then utilized to inform the application of appropriate resources to support members’ health care needs as well as accurate payments and reimbursements. Unfortunately, meaningful disconnects exist between medical documentation and claims data resulting in an incomplete understanding of patient disease status, progression, and care needs, as well as inaccurate payments and reimbursements. As a result, health plans expend significant resources to more accurately understand and substantiate their members’ risks scores.  

While Natural Language Processing (NLP) technologies have been applied within the healthcare industry to aid in the capture and analysis of risk score information, the industry’s currently available NLP solutions struggle to tease out key data points from the medical records without an extremely high false positive rate. Further, today’s solutions fail to provide meaningful targeting insight to guide a clinician, medical record reviewer, or auditor to precisely where an area of concern within a patient’s case documentation may lie. The net result is lower accuracy within risk scores, lower understanding of individual patient’s disease status and care needs, higher costs related to accuracy-improving initiatives, and greater risk to health plans with respect to their inadvertent submission of inaccurate risk score data which can lead to potential legal liability and financial penalties.  

The NLP/ML powered application being developed collaboratively by Inovalon leverages AWS’s Amazon Comprehend Medical® NLP service to derive insights from unstructured clinical text and map clinical concepts to standardized medical codes like ICD10-CM. The enriched output from Comprehend Medical is combined with a logical scaffolding created from Inovalon’s AI/ML capabilities and deep subject matter expertise. The result is an advanced capability to analyze targeted member medical records to identify those that are highly likely to have meaningful disconnects between the clinical documentation and that of the claims data associated with the patient. Additionally, the solution not only is able to determine the probability of such disconnects being statistical true positives, but also highlight where the evidence which supported a concern resides. The result is a solution that empowers users with powerful insights and enriched patient-level data with greater risk score accuracy to augment claim review efficiency and decrease costs. Inovalon expects the application to be generally available early in 2024. 

 “Our focus is on the relentless enhancement of the Inovalon ONE Platform so that we can in turn empower our customers to achieve their missions,” said Eron Kelly, President of Inovalon. “This is the first of several collaborations we are doing with AWS to empower our customers to improve healthcare outcomes and economics through the thoughtful and careful use of AI/ML.”

The No Surprises Act (NSA) is a bipartisan effort to protect patients from unexpected healthcare expenses. This law is good news for patients, with a KFF poll showing that 1 in 3 insured adults between 18 and 64 received an unexpected medical bill in the prior two years. The NSA aims to make the cost of care more transparent and minimize surprise billing, which can cause significant financial burdens through higher out-of-pocket expenses and denied claims. Under the NSA, patients now receive preliminary good faith estimates of care costs and can seek care feeling confident they understand the price. 

While the implications of the NSA are a relief for patients, health plans and providers can’t say the same. Providers are experiencing administrative and payment-related challenges, and payers have to navigate delayed revenue recognition. Since COVID, the frequency providers have updated their data is on the rise, and payers are struggling to keep up. Now, health plans must comply with the regulations of the NSA, making the daunting volume of provider updates even more unmanageable.

The State of Play

Under the NSA, health plans must meet a series of stringent requirements establishing a verification process that ensures the accuracy of their provider directories. Inaccurate provider directories and compliance failures are grounds for hefty federal and state fines. The verification requirements for health plans are as follows:

• Establish a verification and removal process for unverified providers
• Verify and update provider information every 90 days 
• Update payer databases within 48 hours of receiving new provider information 
• Respond to all requests regarding a provider’s network status within 24 hours 

With hundreds of thousands of in-network providers, administrators are burdened with a near-impossible challenge to remain compliant. Unfortunately, many existing provider databases use datacraping and cold calling tactics to gather information, which produces unreliable, sporadic results. 

The Cost of Non-compliance

Imagine for a moment you’re a regional health plan with 40,000 members, and the information in your member directory is inaccurate. The federal government can fine you up to $100 per individual impacted by those errors while also fining providers up to $10,000 for errors. So, if you’ve got 40,000 members, the math becomes pretty compelling to get your data in order. 

An organization in this situation faces more than overwhelming federal penalties; each state can also set its own fines. Altogether, the need to have accurate directories is non-negotiable, and those payer organizations that are unprepared to meet verification requirements will need to make significant adjustments to their business processes to avoid violating the NSA.

Automating the Path Forward

Payers will need to make significant adjustments to avoid violating regulations and incurring these hefty fines, including to how they manage their provider directories. It’s important to note that organizations investing in the tools to keep directories up-to-date can benefit in multiple ways simultaneously.

Simplifying healthcare administration could save the industry $250 billion, but instead, a persistent, antiquated, siloed approach that relies on incompatible systems is trapping data and making the exchange of information slow and complex. If the NSA has made one thing clear, it’s that there is a substantial need throughout the industry for a payer solution that solves compliance issues and automates data management. 

Data delivery and maintenance are among the most prominent administrative headaches payers face, making an automated solution a crucial piece of adhering to federal regulations like the No Surprises Act. Providers and payers need a sophisticated infrastructure that facilitates the seamless exchange of critical information, creating a single source of truth and eliminating inefficient information silos. Furthermore, this type of provider data exchange could simplify transactions between payers and providers so they can stay compliant with the No Surprises Act through real-time provider directory updates. Administrators can focus on other essential tasks when data can be automatically verified and updated in all necessary places.

Undoubtedly, implementing The No Surprises Act was a significant and necessary win on behalf of patients. But the dust won’t settle until payers and providers successfully implement the processes and technology required to consistently meet the NSA verification requirements. The time and costs of completing administrative tasks are already bleeding the industry and eating into quality patient care. Without a strategic, nimble, and automated approach to handling the new requirements, payers and providers alike can expect to feel financial and administrative pain for a long time. 

About Eric DemersEric Demers is the CEO of Madaket Health. He believes we can transform healthcare delivery through the power of data and interoperability. With more than 25 years of global healthcare experience, Eric has built and scaled leading technology and service companies, from early stage to Fortune 100. He is highly sought-after for speaking and consulting on international health, having advised global entities and governments on critical issues facing healthcare. A growth-minded leader, Eric has founded three companies and exited two. Eric previously served in strategy-focused executive roles at IBM, Accreon, MEDecision and Orion Health. He is a graduate of Brandeis University and The George Washington University School of Medicine and Health Sciences.

What You Should Know:

– Rite Aid filed for Chapter 11 bankruptcy protection on Sunday to address its $4B debt load and legal battles for allegedly filing unlawful opioid prescriptions.

– Last Thursday, Rite Aid filed a notice to the US Securities and Exchange Commission (SEC) stating an inability to file its latest quarterly financial report due to exploring “strategic alternatives.”

Interim Plans During Bankruptcy

To support itself during the bankruptcy process, Rite Aid established $3.45B in debt reduction agreements and sold off Elixir to PBM company MedImpact Healthcare Systems Inc. for $575M in cash. In addition, Rite Aid is working with A&G Realty Partners to close more stores to cut down on rent costs of its more than 2,100 locations.  Rite Aid appointed a new CEO, Jeff Stein to serve as the head of restructuring and a board member as the company fights to stay in business.

A demographic shift is looming, and we aren’t as prepared as we think.

Colorado has long been revered for its stunning landscapes and outdoor pursuits, earning a reputation as a state with a youthful and active population – but, we are aging.

By 2050, Colorado’s number of older adults is expected to more than double to 1.7 million, second only to Alaska in the U.S. for the fastest-growing population of people over 65. Nationwide, the 85 and older population is projected to more than double from 6.7 million in 2020 to 14.4 million by 2040. 

The concept of a ‘Silver Tsunami’ goes beyond statistics; it underscores the demand for affordable, quality care for our aging adults.

This puts senior care communities at a critical juncture.

Three key areas are emerging as indicators of a new era in senior living that demand our attention. First, there is the need to enhance staffing retention and cultivate a supported and dedicated workforce. The second involves integrating technology to enrich the lives of seniors and empower caregivers. Lastly, there’s a pressing need to make long-term senior care more affordable, reshaping its accessibility and benefits for everyone.

To fully address the surge of seniors who will require care, we must first transcend quick-fix solutions into more tangible improvements that will prepare the industry for its impending reality.

Balancing Staffing Shortages with the Demand for Care

The scarcity of senior care staff has transformed recruitment and hiring into full-time jobs for communities. This is a result of fewer individuals entering the industry compared to the demand in almost every market throughout the country.

This severe shortage has been worsened by experienced care team members leaving due to burnout, stress, retirement, and other factors. Moreover, it is amplified by growing operational inefficiencies, characterized by miscommunication, delays in sharing information, and fragmented coordination of care.

When multiple providers and care team members work together to care for older adults, it’s essential to have clear and efficient communication, especially for keeping staff engaged. When all caregivers are well-coordinated and informed, it minimizes misunderstandings and mistakes, resulting in happier staff and lower turnover rates

Dispelling the Myth of Senior “Technophobia”

The myth that aging adults are incapable of embracing technology must be debunked. 

The cultural shift towards embracing technology lies with organizational leadership. When these key stakeholders champion the integration of digital solutions, they send a powerful message to staff and residents to explore the potential that technology holds in enhancing their daily lives.

Adoption must begin at the top, with C-suite members leading by example and celebrating the benefits with confidence and enthusiasm. Beyond mere acceptance, they will come to recognize the value that technology brings to their communities, from improved communication and care coordination to enhanced social connections and personalized experiences.

Unpacking the Cost Dilemma

Ensuring the affordability of long-term care for our seniors is a crucial factor that shapes the future of caregiving. This challenge is complex and tied to various financial limitations.

Offering improved pay to staff creates a tough situation for families seeking care. When concentrating on higher wages, the element of keeping staff for the long term is overlooked, causing communities to hurriedly spend money on the issue without planning lasting ways to keep their caregivers.

Increasing food expenses, elevated utility bills, and inflation add to the challenge of affordability, impacting both care communities and families. The discrepancy between Medicaid’s reimbursement rates and the rising care costs compounds the issue, as the number of Medicaid participants surpasses the available rooms or beds. Finding the correct balance between affordable care and high-quality service is necessary for the future of long-term caregiving. 

Shifting Perceptions for Future-Oriented Senior Care

The current model, which is based on an approach from fifty years ago, must be reimagined to fit the unique challenges of today’s senior care environment, which is unlike anything seen before.

To start, we need to change the public perception of senior care and educate consumers about its future. Encouraging everyone to ask, “How will you address my needs when I require your services?” prompts a shift in mindset, driving care providers to adapt their offerings to meet the demands of tomorrow’s seniors.

We also need to nurture a motivated workforce, fostering a culture of development and learning. This means understanding that job satisfaction goes beyond just money – it’s about creating an environment that makes their work more manageable and fulfilling. When caregivers can prioritize the personal connection that seniors crave, it keeps the human touch intact and enhances operational efficiency. This, in turn, can alleviate the financial pressure on communities and families.

To ignore the potential of staffing improvements, technology adoption, and affordability concepts is to undermine the entire industry’s future. This is a call for a shift beyond the immediate, for a forward-thinking vision that reshapes the status quo.

It’s time to break free from the constraints of tradition and lay the foundation for a more sustainable future in senior care.

About Katherine Wells

Katherine Wells is the CEO of Serenity, the only network that allows ageing service providers, older adults, and their loved ones to “care together. In addition to her role at Serenity, she is the Chief Inspiration Maverick at Mavericks of Senior Living, a place to bring together different-minded individuals across the senior living ecosystem to create true innovation, including spearheading a new event called National Collaboration In Aging. Prior to her work in senior care, Katherine spent 25+ years as a software marketing executive. She also spent 10+ years as a family caregiver. Caring for her parents both inspired her to start her company and get more involved in creating a future we all want to live in. Katherine is a frequent speaker and thought leader within the industry, passionate about discussing the topic of ageing.

About Francis LeGasse Jr.

Francis LeGasse Jr. is President and CEO of Assured Assisted Living, whose mission is to improve the quality of life of its residents suffering from various dementias in a residential, home-style, least restrictive, but secure environment.  In addition to his role at Assured Senior Living, he is the Chief Curiosity Maverick at Mavericks of Senior Living, a place to bring together different-minded individuals across the senior living ecosystem to create true innovation, including spearheading a new event called National Collaboration In Aging.

What You Should Know: 

• KLAS Research presented the 2023 KLAS Top 20 Emerging Solutions awards at HLTH 2023, highlighting the top 20 emerging healthcare solutions with the greatest potential to disrupt and improve healthcare. 
• Selected by healthcare leaders working with KLAS, the solutions were rated on how well they could advance the “Quadruple Aim of Healthcare” – improve outcomes, reduce the cost of care, improve the patient experience, and improve the clinician experience. 

KLAS Top 20 Emerging Solutions 

The winners for the “Improve Outcomes” category are:

• SeamlessMD: Patient-Driven Care Management for Preoperative & Postoperative Care
• TransformativeMed: Improving Provider Efficiency by Optimizing EMR Workflows 
• Clearstep: Driving Outcomes through AI Chat-Based Solutions for Triage & Patient Engagement 
• Current Health: Enterprise Care at Home—Moving the Healthcare Market Forward 
• Rhino Health: Facilitating the Creation of Healthcare AI Models via Edge Computing & Federated Learning 

The winners for the “Reduce the Cost of Care” category, are:

• CodaMetrix: Reducing Manual Coding Volumes through Automation & Machine Learning 
• SeamlessMD: Patient-Driven Care Management for Preoperative & Postoperative Care 
• Trulla: Maximizing Pharmacy Savings through Algorithms, Standardization & Preferred Supplier 
• Current Health: Enterprise Care at Home – Moving the Healthcare Market Forward
• Rhinogram:  Improving Patient Communication by Streamlining Administrative Processes

The winners for the “Improve Patient Experience” category, are 

• Clearstep: Driving Outcomes through AI Chat-Based Solutions for Triage and Patient Engagement
• Rhinogram:  Improving Patient Communication by Streamlining Administrative Processes
• SeamlessMD: Patient-Driven Care Management for Preoperative & Postoperative Care 
• Current Health: Enterprise Care at Home – Moving the Healthcare Market Forward
• Steer Health: Engaging Patients Across Multiple Stages of Care

The winners for the “Improve Clinician Experience” category, are:

• TransformativeMed: Improving Provider Efficiency by Optimizing EMR Workflows 
• SeamlessMD: Patient-Driven Care Management for Preoperative & Postoperative Care 
• Clearstep: Driving Outcomes through AI Chat-Based Solutions for Triage and Patient Engagement
• Intelligent Locations: Combining Tracking Technology with Artificial Intelligence in a Comprehensive RTLS Solution
• SocialClimb: Using Healthcare Marketing Software to Automate Patient Growth

What You Should Know: 

– Researchers at the Icahn School of Medicine at Mount Sinai and the University of California San Diego have been awarded an $8.5 million grant to create a data integration hub aimed at accelerating novel therapeutics and cures for diseases within initiatives supported by the National Institutes of Health (NIH) Common Fund.

– NIH Common Fund programs are large-scale projects designed to collect cutting-edge biomedical research data from human cells, tissues, and patients to rapidly advance biomedical research.

The Common Fund Data Ecosystem (CFDE) Program

The Common Fund Data Ecosystem (CFDE) program was created by the NIH to enhance the findability, accessibility, interoperability, and reusability of data generated by NIH Common Fund programs, thereby ensuring adherence to the FAIR guiding principles for scientific data. 

Building on the successes of the pilot phase of the CFDE program, and with a five-year investment of $17 million, the NIH has established two new centers: the CFDE Data Resource Center and the CFDE Knowledge Center. Investigators from Icahn Mount Sinai and the University of California San Diego were selected to lead the CFDE Data Resource Center, and investigators from the Broad Institute of MIT and Harvard were awarded the CFDE Knowledge Center.

Currently, most Common Fund datasets are dispersed across distinct data portals, resulting in underutilization due to the absence of standardized community practices and shared data processing protocols. By enabling seamless discovery of datasets across the Common Fund data, uniformly processing the data, and better combining data from different programs, the investigators anticipate the emergence of synergistic discoveries.

By working with the Common Fund data coordination centers, the Data Resource Center and Knowledge Center are expected to produce highly valuable computational resources for the entire field of biomedical research.

CFDE Key Objectives

The research teams work will involve:

• Establishing a Data Resource Portal to enable user-friendly queries of Common Fund data sets
• Developing the CFDE Portal for the ecosystem, housing information and links to related resources, trainings, and events
• Assisting Common Fund programs in standardizing how metadata, data, and digital resources are handled in the ecosystem, and liaising with other relevant NIH efforts

Leadership

Dr. Ma’ayan and Dr. Subramaniam will lead the Data Resource Center. The Knowledge Center award will be led by Jason Flannick, PhD, Assistant Professor of Pediatrics at Harvard Medical School and the Division of Genetics and Genomics at Boston Children’s Hospital, and an Associate Member of the Broad Institute, along with Dr. Noel Burtt, Director of the Diabetes Research & Knowledge Portals Program at the Broad Institute and Dr. Kyle Gaulton, Associate Professor in Pediatrics at the University of California San Diego.