Geoff Matous

A whirlwind of activity last week at the America's Physician Groups conference. Lots of solid insights shared by health system leaders. Some notable thoughts: +++ Artificial intelligence is intelligent in different ways: By now, we all know ai has a diverse set of use cases, incorporated in different applications and tools. But there are fundamental differences in how the intelligence itself is brought to life. Examples include: - Predictive AI, used to forecast future outcomes by leveraging historical data. Shout out to UCLA’s CKD/ESRD early intervention protocol (Joycee Berin) and Diagnostic Robotics’ intelligence care post-dicharge journeys (Kira Radinsky) - Protocolized AI, used to automating a user’s administrative load by using a set of detailed, pre-defined rule sets. Thanks to ARC for sharing their experience using Elaborate 's automated outpatient lab summaries (Manish Naik) - Generative AI, used to create new content. Great overview of ambient documentation at MGB as well as Cedars’ Sinai talking through its medical ontology model powering acute triage (Caroline Goldzweig) Across system leaders and experts, there was clear agreement that the first step to implementing intelligence intelligently is defining the ‘jobs to be done’. That way, internal and external stakeholders are clear on what they're solving for when they architect the solution.  +++ Scaling AI takes time and rigorous observation: Market leaders describe a phased pilot approach that allows clinicians to build confidence and system leaders to measure ROI before deploying systemwide. Loved hearing Rebecca Mishuris outline MGB’s novel approach of piloting two solutions against one another, to pressure test implementation, workflow, and value creation. +++ Proving ROI continues to be challenging: Lots of vendors using lots of different metrics to prove value, but the majority of leaders agreed that estimating the ROI of these new tools today is part science, part art. Demonstrating the ROI of the “soft” metrics around provider burnout and retention seemed to be a big opportunity, especially for investment in more efficient primary care and PCP wellbeing. After all, PCPs drive referrals to specialty-level care (and higher reimbursements) for health systems. Appreciated Anurang Revri's overview of how working team setup can also impact ROI estimates. +++ Value-based care = tools + humanity: VBC will require not only implementing tools to support clinical documentation, risk capture, upcoding, etc, but also humanizing interactions to engage patients. Countless examples, but one that made me smile was a depression focused chat bot responding in the following interaction: - Context: post-discharge check in Bot: Hi Freida, how are you feeling today after your surgery?  Patient: I’m having a tough time, am in a lot of pain.  Bot: Well, it can’t be that bad, I’m sure it will get better with a positive mindset!    🤣 🤣 🤣 Can't wait for next go-around!

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For all the talk about value-based care, progress still is very slow. Advisory Board data shows the small amount of progress made from 2017 to 2022, which varies drastically by line of business. Medicare Advantage is the primary segment driving VBC, mainly due to aligned incentives where plans and providers could get paid more through upcoding (or "appropriate coding") of patients to drive more revenue & margin through the entire system. That drove penetration of VBC in MA, and CMS has paid attention, releasing significant headwinds (v28, RADV, Stars) aimed at reducing these perceived overpayments. In other segments, VBC has been very slow to grow. Commercial VBC arrangements were essentially stagnant. Anecdotally, this is starting to change. Plan sponsors (employers) -- especially large, sophisticated ones -- are demanding more from their carriers. They want to see network arrangements that impact quality & cost. Will that be enough to drive VBC activity in the commercial space? We'll see. Employers -- the customers -- will be the ones who will drive VBC forward here. TPAs alone don't have the incentive to make changes. I remain hopeful, but skeptical. #valuebasedcare #healthtech #digitalhealth

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Radiologists are achieving payments 500% above the Qualified Payment Amount (QPA) in surprise billing disputes, thanks to the No Surprises Act. This figure is staggering and highlights an important reality: many providers might not realize the tremendous potential of this opportunity. When the No Surprises Act (NSA) was enacted in 2022, the rates at which providers were reimbursed took a major hit, often cut in half. Payors exploited the QPA to justify lower payments, essentially giving themselves the green light to underpay claims. If a provider disagreed with the payment, they had to navigate the cumbersome claims process to recover what they deserved. But here’s the good news: By participating in the IDR process, radiologists are claiming up to 5 times their initial payments. This result is a powerful incentive for payers to engage in a meaningful negotiation and ensure fair compensation. Providers should leverage the NSA to their advantage - and capture every dollar they’re owed.

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Let's keep hospice focused first and foremost on the PATIENT. After all, we only get one chance to do it right... "There are six primary trends that are influencing consolidation and professional practices: regulatory complexity. technology and integration, private equity ownership. demographics, economies of scale and consumer expectations,” Henderson said. “So many of these things that we see that are influencing health care consolidation need to be pointing toward the patient." #patientsfirst #hospicecare #youonlygetoneshot https://lnkd.in/gbbgV-YF

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🤔 How do (US) hospitals spend money 101? Salaries, Wages, Benefits: 45-55% Professional Services: 12-22% Supplies: 12-18% Depreciation/Amortization: 3-6% Other Expenses: 5-20% 8 key insights: n°1. Hospitals consume 31% of US healthcare spending: Despite being the largest spending category, many hospitals struggle with low operating margins, often below 2%. n°2. Labor costs dominate hospital expenses: Salaries, wages, and benefits account for 45-55% of a hospital’s expenditures, with front-line staff making up 75-82% of the workforce. n°3. Contract labor adds significant costs: Hospitals often resort to staffing agencies due to labor shortages, paying 2-3 times more for contract workers compared to employed staff. n°4. Supplies account for 12-18% of expenses: This includes medical equipment, drugs, and personal protective equipment. n°5. For-profit vs. non-profit hospitals: For-profit hospitals tend to manage costs more efficiently, keeping salaries and expenses lower, but often at the expense of services like Medicaid or charity care. n°6. Economies of scale in larger health systems: Larger systems benefit from negotiating better prices for supplies and services. n°7. Rural hospitals face unique challenges: Limited access to talent and capital means rural hospitals must rely more heavily on expensive outsourced labor and struggle to offer high-margin services. n°8. Staffing shortages remain a key issue: Despite financial recovery post-COVID for many hospitals, staffing shortages continue, driving hospitals to explore different revenue models and operational changes to sustain profitability.​ Great post by the Out-Of-Pocket team Nikhil Krishnan & Ben Chao #healthcare

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This 👂 podcast episode and insight’s from a16z Bio + Health's Julie Yoo spoke so clearly to the fundamental challenge facing both 🩺 clinicians and 🏥 healthcare systems.  There is a huge disconnect between supply, in the availability of clinicians, and demand, in the increasing volume and complexity of healthcare needs. -     36% of physicians plan to reduce their hours next year according to the AMA -     48% of physicians reported feeling burned out in a 2024 Medscape survey At the same time, the demographic baby boomer bubble and steady increase in the prevalence of major chronic disease, which consumes up to 90% of healthcare expenditures according to some estimates, is driving demand. With this context, Yoo points to a major opportunity for AI adoption in healthcare in 2025. Yeah, a VC hyping a wave of new AI companies that will replace the decades of training and experience of clinicians, the skeptic would say.  But Yoo is thoughtful in pointing to the role AI can play, and is already playing, through solutions such as ambient, autonomous scribe solutions (of which local star Abridge is leading the pack) in not replacing, but freeing up productivity for clinicians. There is so much unstructured context in both the complexity of disease and treatment options and the social/emotional considerations that we shouldn't be looking for AI to *replace* clinicians. But companies are getting better at finding the structured, repetitive and time-consuming places where AI tools can *help* clinicians. Nearly two-thirds of doctors cited bureaucratic tasks as the leading contributor to burnout. Rigorously trained-AI driven solutions can be a force multiplier for clinicians, and I’ve seen several interviews where nurses and doctors go as far as to say some of these solutions are ”restoring their joy in practicing medicine”. Our health is precious; and we rightly want any technology engaging with it to be developed thoughtfully and thoroughly tested. This requires top AI talent and diverse and realistic training data. Pittsburgh’s strengths in both areas is why we are an emerging hub for data-driven healthcare. #AIinhealthcare #clinicianburnout #healthinnovation #digitalhealth

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Strategies for Success in the Face of Medicare Advantage Challenges As the Medicare Advantage landscape becomes increasingly complex, with regulatory changes, high utilization trends, and funding stagnation, it is essential to identify and implement effective strategies to ensure success. **1. Membership Shifts and Pricing/Benefits Adjustments:** Anticipate shifts in membership and proactively adjust pricing and benefits to cater to the changing needs of the target population. **2. Synergistic Approach to Coding, Quality, Engagement, and Network Management:** Break down silos and establish a collaborative process that integrates coding, quality, engagement, and network management to optimize performance. **3. Utilization Management and Total Cost of Care Control:** Implement strategies to manage utilization and control the total cost of care, including exploring digital, virtual, and alternative forms of care to enhance affordability and accessibility. For further insights and a more detailed discussion, please feel free to reach out directly. #medicareadvantage #affordability #totalcostofcare #healthcareinnovation #optum #utilizationmanagement

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Alot of bad actors and a few good actors. $2.5T HC capital raised & $1T invested by PE in last decade. $31B in 2013 vs. $217B in 2021. We know the story. Misaligned incentives - unrealistic multiples, short-term profit focus, aggressive cost-cutting, unrealistic scaling, misunderstood market dynamics, just to name a few. However, our industry needs money. But our industry is more infrastructure asset class than tech start-up (James Nicholls gave me that epiphany). Mic drop on the lyrical genius of Alex Fair of MedStartr Ventures as he literally gives the whole story poetic justice as he reads HIS POEM on this "On The Road at VIVE" episode of The Reverse Mullet Healthcare Podcast w/BP2 Health. This is the perfect episode for a Friday afternoon! He and Paulo J Machado donned the actual reverse mullets and joined us back in February at #VIVE2024 to talk about the need for REAL change in healthcare, startup focus and investor expectations. It was one to remember and one that is in desperate need of a full-length follow-up episode. Give us a like and a watch or a listen https://lnkd.in/e4w4mjkv https://lnkd.in/egmK3kMB

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The US Physician Workforce will be decimated by the boomer doctor retirement cliff between now and 2030. A disturbing pattern in recent study findings makes this issue much more urgent - and the timeline to impact much shorter - than the government predictions. Let me show you why. The new statistics, the references ... everything The dots will all line up when you watch this short video and I'm happy to have the chance to show them to you. If you are a physician leader, this video is a Must-Watch because the mainstream media is not covering this phenomenon. Employers are only focused on short-term results: the numbers at the end of this second quarter, or the end of 2024.  They don't see this long-term trend. I also strongly recommend you share these videos with your C-suite - especially if your organization does not have a Corporate Wellness Strategy in place at this time. Learn what to watch out for - and what you must start doing now - to implement a Physician Wellness Strategy while there's still time. This trend will play out over the next three or four years. It's inevitable. You can't fight father time and nobody's getting any younger. Every doctor needs to know what is coming. Watch these short outtakes from this week's Wellness Champion Summit Webinar https://lnkd.in/gFYckWS4 **You will learn** 👉 What is the Boomer Doc retirement cliff? 👉🏽 How bad is it? 👉🏿 Recent changes in female physician and medical student behavior make things much worse. 👉 How the answer to this one question to your CMO doubles the projected physician shortage of 2030. 👉 Does AI at the same time make things better or worse? 👉🏿 What your organization must do now to prepare. 👉🏽 Why I'm predicting a brief window of opportunity for a corporate Physician Wellness Strategy - but you must act now!

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Great article from Katie Adams from MedCity News interviewing Lee Schwamm, MD. These are three great nuggets. I've built for clients the digital front door wrapper he's referencing. Depending on the maturity and budget availability of an organization, I would argue it's possible to do this even without the software development kit. Unfortunately, those can be cost prohibitive and inaccessible for many health system teams with limited expertise and bandwidth. I do wonder about how an LLM could work to overcome both a wide range of ways a patient might describe their condition and looming challenge information asymmetry between clinically trained knowledge and patient knowledge? Would it be trained to be so risk averse to still always default to an overrun primary care system? Would it really enable to bypass to a specialist when there might be access issues or referrals needed for that specialty? I really like the insight from Lee about the "mid-level, consistent, reliable experience." He talked about this at the Reuters Events Healthcare in San Diego a few weeks back and I still like it! Overall - great article Katie and Lee! https://lnkd.in/gyMRaMKh

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Weekly lessons learned - Where did that $200 Billion of acute care revenue go? Hospital C-suites, Carter Williams and I did quick math >$200 BILLION in acute I/P revenue will evaporate if just 25% of those w/1 chronic condition take a GLP-1 and 50% of those avoid 1 hospitalization. This aligns w/Yubin Park, PhD recent data on ACR which would only add to this estimate. And hims & hers is showing this revenue shift real time with a 70% YOY increase Matthew Holt. Even 23andMe is making a comeback play w/Lemonaid Health (part of 23andMe) Sergei Polevikov, ABD, MBA, MS, MA 🇮🇱🇺🇦 Sticking w/"meanwhile an entirely new healthcare ecosystem is being built and we are still focused on heads in beds" 🙄 Superpower and Max Marchione went live with their beta and a video that liteally compares him to Steve Jobs, Bill Gates, Elon Musk and Jeff Bezos in 0:38 sec., well alrighty then. As of now it's a marketplace w/diagnostic testing akin to Function Health (on steroids) comingsoon. Josh Erndt-Marino 😉 One of my favorites Michael Muntner at Crestview Partners announced Cardinal Health has added a GI MSO and Advanced Diabetes Supply to its portfolio 😉 Thatch Chris Ellis is partnering with Quickbooks (hello 1 million small businesses) to bring ICHRA to the masses, hope POTUS doesn't kill it - Brad O’Neill Brendan Keeler was on fire pointing out that AI is actually live on Epic, TEFCA vetting process update and a substack piece for the ages chronically Epic's battle scars and brokedown AI w/impacts, Patrick McGill, MD MBA calls copilots a game changer and Christina Farr added to this by asking - Is AI "time savings" going to mean doctors and care teams get more time with their existing patients than the 6m visit? or have to do more... When will we learn our bricks and mortar lesson?! Forward Health literally imploded in a matter of months after burning $100M largely on pods Guy Culpepper, MD In food news 🥕 Dear health systems you have better choices than Sodexo! Matriark Foods (Anna Hammond) is now a Vizient, Inc #environmentallypreferredsupplier - you can impact your Scope 3 emissions goals AND provide healthy delicious foods to patients 🥑 If you don't know Clancy Harrison and The Food Dignity Movement you should If Robert F. Kennedy can steer clear of reversing vaccines, maybe he really can help "Making America Healthy" - #foodishealth vs. #pharmaisking. Graham Walker, MD Andy Mychkovsky Erin W. Martin Billy Wynne did a great piece in Health Affairs about what the election could mean for HC and Andrew Schwab continues to share great post election intel and Sachin H. Jain, MD, MBA weighed in on MA impacts For my next rabbit hole this week - the report for Accountable Health Communities Model is out Darshak Sanghavi along w/2023 ACO REACH 2023 results next week. $1.6B program savings results which Chris Deacon pointed out could in fact be losses via evaluation findings - I'm conflicted - after working with so many ACOs I know they create true value.

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I get Dr. Yang's concern about large, wealthier health systems adopting AI sooner than smaller, poorer organizations, but this is actually a good thing...unless your time horizon is myopically short. Big organizations, with much larger budgets and sophisticated IT teams, can afford to take risks, make mistakes, and test out exciting (but still unproven) emerging tech while smaller organizations certainly can't (for the most part). So let the behemoths take all the risk, do the heavy lifting first, and then smaller organizations get to adopt truly proven solutions at lower risks/prices...once these have run the Kaiser, Mayo, Intermountain, etc., gauntlet. It's all part of the plan... #healthcare #startups #startup #ai #generativeai #digitalhealth #emergingtech Kaiser Permanente Cleveland Clinic Mayo Clinic Risant Health Intermountain Health https://lnkd.in/gckgQB_q

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Great breakdown from McKinsey & Company here on current Medicare Advantage dynamics. TL;DR they have some levers but margins are as thin as they've been in recent memory in 2024. McKinsey called out the following as challenges for MA players moving forward: -Little to no rate increases from CMS -Broker commissions changes -V28 changes -Star ratings (the biggest near-term lever) -Utilization trends -Part D and other regulatory changes Source: https://lnkd.in/g9U4h2Gp

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Each year, Modern Healthcare's Top 100 includes numerous CEOs from massive hospital systems, PBMs, digital health/technology companies and carriers whose actions have played a significant role in creating the most expensive healthcare system in the world, one that delivers shockingly poor outcomes. It’s no surprise, given that many of these institutions are prioritizing profits over patient care, and in some cases, they’ve been found guilty of practices that harm both taxpayers and vulnerable populations. Let's take a look at some of the past honorees—leaders from companies like Tenet Healthcare, which paid over $500 million in fines for defrauding Medicaid and exploiting pregnant women through illegal kickback schemes, or Pfizer, whose $2.3 billion settlement for fraudulent marketing was the largest healthcare fraud case in history. UnitedHealth Group leadership always makes the list and has faced multiple False Claims Act lawsuits for inflating Medicare Advantage payments, and Oak Street Health, under Annie Lamont, recently agreed to pay $60 million to resolve allegations of kickbacks in Medicare Advantage recruitment. Centene Corporation, led by Sarah M. London, has paid billions to settle claims of overcharging state Medicaid programs. UPMC, RWJBarnabas Health, AdventHealth, Ascension and other hospitals' leaders are always on the list. And we cannot leave out Steward Health Care's Ralph de la Torre. He has made the list multiple times, including as recently as 2021. In all fairness, the list is "most influential," not necessarily "most influential in a good way..." Look, It’s not about the list itself, but imagine the powerful statement we could make if those who want real change inundated Modern Healthcare with a new kind of nominee. It would serve as an indictment of the current system—a call for leaders like Marilyn Bartlett, Cynthia Fisher, Dave Chase, Health Rosetta-discovering archaeologist, Kevin Lyons, Dave Chase, Health Rosetta-discovering archaeologist, Hugh O'Toole, Ryan Kline, Mark Cuban, Scott Conard, MD, Stacey Richter, Ann Lewandowski.... those who are genuinely working to reshape healthcare for the better. Let’s show that we demand integrity, transparency, and results—not just shareholder returns and growth. Make your voice heard- it’s time to send a message to the industry that we want a different kind of influence—one that is about integrity, transparency, and results for the American people. #healthcare #leadership #changemakers #modernhealthcare #nominate #transparency

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When the Digital Health Awards categories came out this year, we were thrilled to see one called "Biggest Healthcare Savings Story". Oshi Health continues to demonstrate total cost of care savings: first in a clinical trial, then in 18 months of a value-based contract with a national payer and now with dozens of employers over multiple years. When you provide high-touch care that identifies root causes of #digestivehealth conditions and helps patients gain control of their condition, the cycle of repeated diagnostic testing and emergency room visits stops and total cost goes down. We are honored to be a finalist in this important category! #valuebasedcare #wholepersoncare

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Key Metrics a Virtual Hospital Manager Should Monitor In the rapidly evolving landscape of healthcare, virtual hospitals are at the forefront of leveraging technology to provide accessible and high-quality care. For a virtual hospital manager, monitoring key metrics is crucial to ensure smooth operations and optimize resource allocation. Appointment and Patient Flow Management Completed Appointments: Track successfully completed appointments. Cancelled Appointments: Monitor cancellation rates. Pending Appointments: Keep an eye on appointments awaiting confirmation. Geographic Distribution Patient Distribution Map: Visualize patient numbers from different regions. Service Coverage Areas: Identify high-demand regions. Service Performance Average Service Time: Measure service completion times. Patient Satisfaction Scores: Analyze feedback to improve services. Resource Utilization Staff Workload: Track patient numbers seen by healthcare professionals. Equipment Status: Monitor availability and functionality of medical devices. Emergency Management Emergency Calls: Track number and nature of emergency calls. Response Times: Measure emergency response times. System Health and Security Server Performance: Monitor IT system health. Data Security: Track security incidents. Financial Performance Revenue and Expenditures: Monitor income and operational costs. Insurance Claims: Track processed claims and billing accuracy. AI and IoT Integration Diagnostic Accuracy: Measure AI-based diagnostic tools' accuracy. Remote Monitoring: Ensure IoT devices are properly connected. By prioritizing these metrics, virtual hospital managers can create a responsive, patient-centered healthcare environment that meets the needs of a diverse and dispersed patient population.SEHA AL RAHBA HOSPITALSanalBeePudena Health Consulting Co.Mustafa Köroğlu

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I hole heartedly agree Benjamin Schwartz, MD, MBA. Anywhere else in an economic system, innovators who can deliver a better product at lower costs are almost always rewarded with greater market share, and frequently set the direction for the future of a product or industry. Not so in healthcare. I think that Terry Adirim, MD, MPH, MBA (below) hit the nail on the head when she references for-profit health insurers in the mix. Although policies have been enacted with the idea of providing better healthcare at lower costs, they have always given the job of administering those policies to a middleman (insurance companies) whose motives are at odds with the objective they claim to be administering. Profit! Innovation is not in the best interest of the payer. They profit through the inefficiency of the system. Until this lack of alignment between quality patient care at low costs and for-profit health care plans is addressed, process innovation and improvement will only be able to nibble at the edges.

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