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March 14, 2023 News 10 Comments

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Stat reports that Medicare Advantage plans are using “unregulated predictive algorithms under the guise of scientific rigor” to cut off payment for the treatment of seniors.

A palliative care facility official says that “the appeal outlasts the beneficiary” as people who will die within three months are forced into an appeals process that takes up to 2.5 years. A Medicare beneficiary lawyer says that her MA patients start getting payment denials 14 days into their SNF stay even though they are entitled by traditional Medicare to stay up to 100 days.

Former CMS Administrator Tom Scully founded NaviHealth after seeing how nursing homes nearly always keep discharged Medicare Advantage patients for the full number of days of their coverage, sold the company for $410 million to Cardinal Health, who then sold it to a private equity firm that paid $1.3 billion, who then sold it to UnitedHealth for $2.5 billion. The company manages post-acute care for insurers who contract with the company for a share of the savings, with providers saying that the number of denials increased greatly when the company changed hands.

A hospital case manager reports, “NaviHealth will not approve [skilled nursing] if you ambulate at least 50 feet. Never mind that you may live alone or have poor balance. MA plans are a disgrace to the Medicare program, and I encourage anyone signing up to avoid these plans because they do NOT have the patients best interest in mind. They are here to make a profit. Period.”


Reader Comments

From Zoey: “Re: ChatGPT. It’s going to get wild when Open-AI releases the new, much more powerful GPT-4 next week.” I’m paying for access to ChatGPT just for my own education, so the GPT-4 model came live for me midday Tuesday (and is also live in Bing’s AI search preview). “Wild” is probably a good word to describe what will happen when AI goes broader and deeper into even more questionably sourced information. Bigger computing power or broader sources aren’t necessarily better for AI training. Would you want your doctor diagnosing you from a system that was trained on Internet junk content, or would it be better to train a system only on medical literature to accomplish that? We saw that in the early days of Internet search, when the novelty of being able to find anything wore off and the quest for higher-value, higher-relevance information that is tailored to individual searchers became obvious. For example, AI could analyze a patient’s EHR to provide clinicians with critical information that is hidden among the chart bloat, although daily batch training would be necessary to avoid limitations as in ChatGPT’s knowledge cut-off of September 2021. Oracle is in an ideal position to do this with its Cerner EHR.

Speaking of AI, the new version of Google’s Med-PaLM medical domain AI tool – which was the first to “pass” the US medical board test last year with a score of 60%, scores 85% at “expert” doctor level. Apparently that model is trained on valid medical information, which Eric Topol, MD says will soon allow AI to create office notes, manage prescriptions, schedule appointments and labs, obtain pre-authorization, and aggregate and summarize medical records.

From Moneylender: “Re: SVB. VCs created their problem and will benefit from the government’s solution.” Agreed. Some VCs and pundits stirred up Internet mob mentality by urging people to withdraw their deposits from SVB and the banking system isn’t set up to deal with a bunch of me-me-me Internet-fueled toilet paper hoarders. Banks and stock markets require people to believe that they are stable, well regulated, and fair to all participants (the equivalent of the Monty Python sketch about buildings that start to fall once you stop believing that they won’t). Note to CEOs willing to learn from SVB’s former one: never publicly use the phrase “don’t panic” since that acknowledges the fear that people are indeed panicking, which like the aforementioned toilet paper hoarders, doesn’t matter whether it’s justified or not.

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From Desert Frosé: “Re: Larry Ellison. Is he trying to train ChatGPT with misinformation or something by bragging on the ‘one patient, one record’ accomplishments of four Epic clients?” I honestly don’t know why he brought that up in the earnings call, where he seems to take credit for Epic’s interoperability in four of its big customers.


HIStalk Announcements and Requests

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Welcome to new HIStalk Platinum Sponsor HealthMark Group. The Dallas-based company is a leading provider of digital health information management solutions for healthcare providers across the country. Guided by over 15 years of experience in healthcare IT, HealthMark helps organizations transform administrative processes into seamless, digital encounters. It provides medical, billing and imaging record release as well as FMLA and audit support. Its technology-driven approach to managing medical record requests improves patient satisfaction and keeps patient data secure and compliant. Thanks to HealthMark Group for supporting HIStalk.

Here’s a HealthMark Group explainer that I found on YouTube.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre to present your own.


Acquisitions, Funding, Business, and Stock

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The FDIC transfers all deposits of Silicon Valley Bank to a new bridge bank headed by Tim Mayopoulos, formerly president of mortgage startup Blend and a former Fannie Mae CEO. The government will protect depositors of Silicon Valley Bank and Signature Bank, using a funding program that offers banks loans against securities to avoid emergency asset sales. The FDIC fund, financed by banks rather than taxpayers, will protect depositors but not investors or creditors. However, the majority of SVB’s clients are venture capital firms and their portfolio companies, not small depositors who will benefit from government support. SVB remains open and assures investors that they will have full access to all of their deposits beyond the FDIC’s $250,000 of insurance.

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Bardavon Health Innovations acquires injury prevention company Preventure to expand its worker and health mobility solutions into a complete, end-to-end musculoskeletal solution. Its Safety Intelligence Suite includes customized injury prevention solutions, an AI movement coach, digital and human interventions, and use of engagement data to determine rehabilitation protocols for improved return-to-work times.

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Tegria rebrands its RCM business as Acclara, naming Tegria RCM managing director Lincoln Popp as CEO.


Sales

  • Providence will offer remote physical therapy services from Luna.
  • Prime Healthcare (CA) selects Ceiba Healthcare’s Integrated Virtual Care technology for tele-neurology, tele-stroke, and virtual critical care services.

People

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Ray Gensinger, Jr. MD (Hospital Sisters Health System) joins Tegria as SVP/chief medical officer.

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Broward Health (FL) names Steven Travers (USA Health) CIO.

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Philips hires Julia Strandberg, MBA (Pear Therapeutics) as chief business leader of its Connected Care business.

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Pivot Point Consulting promotes Max Hanner to SVP of business development, Laura Kreofsky to SVP of advisory, Zack Tisch to SVP of innovation and life sciences, and Jillian Wood to SVP of strategy and transformation.

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Carium hires David McCormick, MBA (Innovista Health Solutions) as COO.


Announcements and Implementations

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Ellkay releases LKOpera, an interoperability platform that allows partners to executive a connected digital ecosystem that accelerates go-lives and gives teams full control and transparency.

Children’s Wisconsin integrates Xealth’s patient education software with its EHR.

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Avaneer Health launches a blockchain-based data-sharing network for payers and providers that aims to improve administration workflows. I remain just as skeptical of blockchain-based healthcare solutions as I did back in 2021, when the company launched: “Blockchain is a hammer looking for nails that never seem to get pounded, and while healthcare has a ton of inefficiency and lack of interoperability (weren’t government-subsidized EHRs and HIEs supposed to fix those problems?), the historic safe bet is to be skeptical of companies that pre-profess their technology’s ability make it better.”

UCHealth’s “no-touch estimate” function is serving 36,000 patients per month with no manual work, generating 99% of patient estimates from Epic in which 72% of them estimate the patient’s portion within 5% or $50 of the final billed amount.

PeriGen launches automated quality reports for L&D that review hypertension recognition and response, perinatal core measure 06 (PC-06) unintended harm in the newborn, and persistence of concerning FHR conditions over time.

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A new KLAS report on clinical documentation strategies finds that Nuance’s DAX ambient speech recognition shows initial promise, but front-end speech recognition is becoming the go-forward platform, led by Nuance Dragon Medical One. Computer-assisted physician documentation offers benefits but low physician buy-in, with Nuance CAPD leading the category. Users of Clinical Documentation Integrity solutions, where Iodine Software and Nuance are the top category scorers, believe that development has stagnated with some vendors. Transcription services are on the wane, and while 94% of users of virtual scribes report positive impact, quality is inconsistent, especially when the assigned scribe is replaced.


Government and Politics

The VA publishes an EHRM Sprint Report acknowledges that the Oracle Cerner implementation “has not met Veteran or VA expectations,” but places the blame on the VA itself for failing to standardize processes and fix issues that arose in its initial deployments. The VA will:

  • Analyze the EHR’s safety performance using Leapfrog’s tool.
  • Improve over-the-shoulder support based on best practices from other health systems.
  • Modify PowerPlans to support research.
  • Prioritize new service requests using a patient safety framework.
  • Create a site readiness dashboard for go-lives.
  • Get live sites back to baseline productivity before bringing new sites live.
  • Simulate patient safety risks at the VA National Simulation Center or other locations.

Other

Scripps Health lays several dozen employees, most of them in IT, according to LinkedIn commenters.

Grady Memorial Hospital in Atlanta sues two apparel companies over their allegedly unauthorized use of the phrase “Grady Baby.”

This could be a public service announcement for choosing both friends and alcohol consumption wisely. Doctors in Nepal remove a vodka bottle that had been inserted in the lowest part of the lower GI tract of a drunk man by his “friends”. A similar incident occurred nearby a few days before, when a group of party-goers decided to see what would happen if they inserted a 3×5 inch steel drinking glass into the nether regions of their drunken bro.


Sponsor Updates

  • WEDI features Arrive Health CEO Kyle Kiser on its latest podcast, “Lucy Up! Improving Patient Access, Affordability, and Outcomes.”
  • Lumeon names Jennifer Bowman (Molina Health), Karen Cox, RN (Chamberlain University), Christy Dempsey, RN (Press Ganey/Missouri University School of Nursing), Jessie Israel, RN (Denver Wellness Associates), and Timothy Zoph (McKinsey) to its new Thought Leadership Council.
  • Baker Tilly publishes a new case study, “Health system realizes cost savings by outsourcing system integration and ad-hoc IT projects.”
  • Sentara Healthcare (VA) and Hollywood Presbyterian Medical Center (CA) use Wolters Kluwer Health’s Ovid Synthesis Clinical Evidence Manager to enhance their clinical research programs.
  • Agfa Healthcare will introduce its Imaging Health Network at HIMSS23.
  • The HLTH Matters Podcast features Biofourmis co-founder and CMO Maulik Majmudar, “Harnessing the Power of Tech and Data to Bring the Right Care to Patients, No Matter Where They Are.”
  • E-prescribing software vendor DAW Systems implements Arrive Health’s real-time prescription benefit technology.
  • Medhost joins the CommonWell Health Alliance.

Blog Posts


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Currently there are "10 comments" on this Article:

  1. It’ll be really interesting to see how much risk tolerance healthcare providers and vendors have related to AI in the upcoming months. If AI can scan a note but they are wrong even .1% of the time, is that acceptable?

    • My feeling is that the risk tolerance varies according to the roles they play.

      Providers will be uncomfortable with AI risk. Vendors, HMO’s, health networks will be quite willing to take some risk, but only if it saves them some money/time/resources. Patients will likewise be AI risk averse, but may not have a voice in this decision.

      The real question is, could the AI be better than trained transcriptionists in some ways and worse in others? And what is the net of that situation?

      We are more comfortable with human caused errors because we understand how those people and systems work. AI is the new thing and has to prove itself to us. That could be the key challenge.

  2. Had the exact same problem ….My 90 YO mom experienced a pontine strike and the SNF was attempting to push her out after 10 days, Stating the UPMC MA plan was dictating the discharge. UPMC MA was not following Medicare law or guidelines, but there own protocols. Working with the non profit Center for Medicare Advocacy (https://medicareadvocacy.org/), we were able to invoke with the UPMC CEO and legal team the class action suit called Jiminez vs Sebelius, which speaks to the requirements of Medicare Payors and Providers. The biggest hurdle beyond the insurer, is the SNF, who is filled with fear of the big insurance company kicking the SNF out of their network should they challenge them and advocate for the patient. Essentially, the SNF is beholden to the insurer… a bit of Stockholm syndrome…. Eventually, we prevailed after having to escalate to the CEO of UPMC and engage an attorney…. MA plans are endangering lives…. fox guarding the henhouse…. and vulnerable seniors are signing up because ” Joe Namath” and others tout them on commercials….

    Hopefully, this info helps save someone you love as well

  3. Oh come on Questioning. The best speech recognition is worse than that. It makes errors and my notes all the time, in I don’t see them until months later.

  4. NaviHealth: The one of only a handful of health AI company that I am aware of that has made any money in the last decade. And wouldn’t you know it – it is by denying coverage. AI or not – shafting patients and tax payers is the only way to make money in our industry and all parties – payers, health systems, PE owned practices, standalone ERs, pharma have gotten very very good at it. And then, there’s the Medicare Advantage – no wonder Humana is dropping all other business lines.

  5. Re:

    ” EHRM Sprint Report … places the blame on the VA itself for failing to standardize processes and fix issues that arose …”.

    This is what I want to know, specifically with regards to standardizing processes. We’ve learned that the VA had 130 instances of VistA, and the Cerner implementation is only going to have one.

    That’s a big change. Each of those 130 instances is an opportunity for a different way of doing things. A single instance is a classic consolidation play, but it must be planned for. You have to engage with the clinicians in a big way, often starting with people like the CMO’s and CMIO’s, and then working your way down.

    This takes serious commitment to workflow changes, some culture changes, detailed assessments of what should be the clinical processes and why. The EHR is often blamed when this goes wrong. And this is a difficult charge to defend against!

    A new EHR is commonly the reason such changes are made. The EHR becomes the reason and justification for standardization. However the issue of standardization itself is actually outside of the EHR implementation, and if you dig in deep enough, you often discover this: Most process variation didn’t help clinical outcomes and indeed often failed to follow clinical best practices. Thus, you can make a case for process standardization even without the EHR.

    The new EHR is a forcing mechanism. The reputational hit of strained relations due to implementation woes accrues to the EHRM project. That’s the political reality and you’d better plan for it.

  6. RE AI and Chat GPT
    It will be all fun and games until a death or two occurs – from uneducated and uninformed denials of care to bad clinical “decisions”.

    • MSFT laying off its entire Ethics & Society team as part of their restructuring to accelerate use of generative AI actually gives me a physical reaction, like fight-or-flight anxiety.







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