Patrick Carroll

CHIA has released its annual update on provider price variation in the Massachusetts health care market. Consistent with trends since CHIA began monitoring price variation in 2012, 𝗵𝗼𝘀𝗽𝗶𝘁𝗮𝗹𝘀 𝗶𝗻 𝘁𝗵𝗲 𝗵𝗶𝗴𝗵𝗲𝘀𝘁-𝗽𝗿𝗶𝗰𝗲𝗱 𝗾𝘂𝗮𝗿𝘁𝗶𝗹𝗲 𝗿𝗲𝗰𝗲𝗶𝘃𝗲𝗱 𝗻𝗲𝗮𝗿𝗹𝘆 𝗵𝗮𝗹𝗳 𝗼𝗳 𝗮𝗹𝗹 𝗵𝗲𝗮𝗹𝘁𝗵 𝗶𝗻𝘀𝘂𝗿𝗮𝗻𝗰𝗲 𝗽𝗮𝘆𝗺𝗲𝗻𝘁𝘀 in calendar year (CY) 2023. 𝗥𝗲𝗹𝗮𝘁𝗶𝘃𝗲 𝗽𝗿𝗶𝗰𝗲 (RP) illustrates the average price for each hospital and physician group compared with a payer’s network average price, accounting for differences in how much care a patient needs, types of services provided, and insurance product types offered (such as HMO or PPO plans). A similar metric, statewide relative price (S-RP), is also calculated for acute hospitals and illustrates the average price charged by an acute hospital across all commercial payers in Massachusetts. 𝗔𝗱𝗱𝗶𝘁𝗶𝗼𝗻𝗮𝗹 𝗸𝗲𝘆 𝗳𝗶𝗻𝗱𝗶𝗻𝗴𝘀: ♦ The lowest-paid acute hospital had commercial prices almost 25 percent below average while the highest-paid acute hospital’s prices were nearly double the average.  ♦ All four acute care hospitals in the Cape and Islands region had above-average cross-payer relative prices.     ♦ Academic medical centers had the highest median S-RP at 1.12, indicating that these hospitals had prices about 12 percent above the statewide average. Community hospitals, teaching hospitals, and community-high public payer (HPP) hospitals had median prices 6 percent to 8 percent below the statewide average. ♦ Among physician groups, the share of payments going to the quartile of providers with the highest RPs continued to grow, increasing by 8.5 percentage points to 55 percent of payments from 2021 to 2023.      This update features an interactive dashboard with payer-specific RP results for all hospital types and physician groups as well as cross-payer S-RP results for acute care hospitals. Access the full report and explore the dashboard online: https://lnkd.in/eNeQQdDx  #MassCHIA #HealthData #HealthPolicy

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This week, the Medicare Payment Advisory Commission (MEDPAC) issued their annual report and recommendations to Congress for Medicare rates in 2027. While not law, this report creates the basis for the discussions on Capitol Hill and within CMS. The proposed changes provide little if any relief to the challenges facing providers. MEDPAC recognizes the hospital Medicare negative margins being -12.1% but set a pace of rate increases that are below inflation. Post acute care providers are hardest hit with 7% reductions for inpatient rehabilitation facilities and home health agencies, skilled nursing facilities would see a 4% reduction and hospice would have no rate increases in 2027. So, where there are negative margins, there is nothing to meaningfully offset the losses and where there are positive margins, there are rate reductions to bring them down. I would like to hear your thoughts on the MEDPAC recommendations, where you think the rate adjustments could end up, insight on the Medicare Safety Net Index, and actions you may be contemplating. https://lnkd.in/eEwqNh3U Healthcare Financial Management Association (HFMA) American College of Healthcare Executives AAMC America's Essential Hospitals HealthLeaders Exchange Becker's Healthcare PwC Deloitte Craig Brondyke, Rich Toner, Michael Rossi, CPA, FHFMA, CSBI, CHCRS

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Fitch Ratings reports that while *hospital liquidity* remains robust—thanks in part to strong investment income—challenges like market volatility, higher costs, and policy shifts cloud the long-term outlook. Hospitals are urged to maintain healthy reserves as a buffer against rising labor and supply expenses, potential tariff impacts, and ongoing reimbursement uncertainties. Strategic liquidity management is now essential for long-term resilience in healthcare. Source: https://lnkd.in/eMvCX7My

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While most #MedicareAdvantage plans and their providers are entering the holiday weeks focused on their feedback to the 2027 Proposed #MA Rule, #CMS quietly released the 2025 Measures Under Consideration (MUC) List which signals the direction of future new measures. These measures shape the future of all CMS quality programs, including #StarRatings in MA. Here are a few highlights of the 24 new measures under consideration: ‼️ 96% of measures under consideration exclusively use digital data to reinforce CMS’ interoperability priorities ‼️ 75% are outcomes-focused to promote alignment and improved health outcomes across the patient’s health journey ‼️ 30% are focused on chronic conditions and related acute events, while 25% actively address safety The 24 measures on this year’s list include 18 outcomes measures (including PROMs), 5 process measures and one structure measure.  While some of these measures are wrapped in MAHA-branding, their core is solid and will likely survive future administrations. Here are a few examples: ⭐ New “BMI Screening and Follow-up Plan” measure (to tackle obesity….for you Stars OGs out there, can you believe a BMI measure might come back???) ⭐ A HOS-like measure named “Wellbeing Signs” asking patients how well they are able to do what matters most to them. ⭐ A “Discharge Function” measure to evaluable a patient’s ability to walk, eat and stand prior to discharge. For our Quality friends, these measures are open for public comment through the Pre-Rulemaking Measure Review (PRMR) process through January 6. If you’re curious whether to invest the time over the holidays to respond, this would be a great time to review the list and think about how your organization would be impacted with more digital HEDIS or outcomes-focused HOS measures, or impacted by more rapid measure development and addition to Stars (as signaled in the MA Proposed Rule) and what you’d like measure stewards to understand about how adding these types of measures would impact your organization. If you’re still working on your Proposed Rule feedback to CMS, we encourage you to include feedback on the themes of the MUCs in both submissions to ensure your voice is heard. Link to CMS publication: https://lnkd.in/gMmRPwtF

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A healthcare group just avoided a massive compliance problem.  Here's what happened.  They were launching a new service line. Huge opportunity. Better outcomes for patients, new billable service line for the practice.  They had several technology partners eager to work with them. The platforms looked solid. Pricing made sense. After evaluating their options, they chose a partner and got ready to move forward.  Then they dug into the compliance side.  What they found wasn't just a red flag. It was a deal breaker. The technology partner's approach put patient privacy at risk and would have exposed the practice to serious liability.  So the healthcare group walked away and built their own platform instead.  Smart move. They protected their patients and their organization.  The reality is, when you're choosing partners, their compliance program reflects directly on you. Your due diligence on the front end determines what risks you're taking on.  That's why I tell healthcare leaders: vet your partners like you'd vet your own team. Because once you sign that contract, their compliance problems become yours.  Always here as a resource, message me.  -RRR

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𝗛𝗲𝗮𝗹𝘁𝗵 𝘀𝘆𝘀𝘁𝗲𝗺𝘀 𝗿𝗮𝗺𝗽 𝘂𝗽 𝗱𝗶𝘃𝗲𝘀𝘁𝗶𝘁𝘂𝗿𝗲𝘀 𝘁𝗼 𝗿𝗲𝗳𝗼𝗰𝘂𝘀 𝗮𝗻𝗱 𝗳𝗿𝗲𝗲 𝗰𝗮𝗽𝗶𝘁𝗮𝗹 Health systems are stepping up divestitures and joint ventures to shore up finances ahead of looming reimbursement cuts. Non-core assets, such as labs, long-term care facilities, and real estate, are being sold or spun off, and some hospitals are being sold in markets where systems lack sufficient scale. The goal is to free up capital for reinvestment in ambulatory and specialty services.  - Ascension has exited markets like Binghamton, NY, and Michigan, selling hospitals where it lacked scale, while refocusing on ambulatory care with a $3.9B deal for 250 Amsurg surgery centers.  - OhioHealth sold select lab services to Quest Diagnostics, which can manage volumes more efficiently and reduce costs, freeing OhioHealth to channel capital into oncology and women’s health. Executives say these moves are less about distress and more about long-term strategy: simplifying operations, gaining cash reserves, and partnering with specialized operators. Analysts note that the trend reflects a broader rethink of what services health systems must own versus what can be outsourced or managed with partners.

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More sobering news for value-based care. Avalere's recently released analysis of 18 CMMI payment models showed that most lost money -- $6.4 billion over the last decade to be exact. A few community pilots saved around $2B, but the broader picture is less favorable. Maryland's All Payer and Total Cost of Care Models performed the best while one Medicare Advantage and two Primary Care models had the biggest losses. Only 4 of the 18 models demonstrated clear impact on quality. None of the models were endorsed by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) which "provides a forum where those in the field may directly convey both their ideas and their concerns on how to deliver high-value care." The analysis follows a 2023 CBO assessment that found CMMI increased the indirect spending by $5.4 billion over a decade. The simple truth remains: our value problem is primarily an infrastructure problem. VBC can’t be retrofit onto fragmented systems and expected to achieve its intended goals. It's time to rethink what VBC means and how to implement it effectively. Some thoughts: 1. Rethink CMMI’s role. Instead of designing and managing models, fund them. Time-limited grants. Measurable milestones. A formal fast-track for exploratory care models that are truly innovative. 2. Full support for new operators. Privately funded and independently developed platforms can build novel care systems with less bureaucracy and administrative burden. Deeply integrated, specialty-first, tech-enabled. They don’t need risk models to deliver great care; they do it inherently. 3. Reframe the narrative. Maybe it’s time to stop chasing “VBC” as a nebulous, undefinable concept and start building actual advanced care models—ones that optimize for quality, experience, and cost without needing policy tailwinds to function. Not value-based care but the natural progression of a better approach. The dream of high quality, engaging, cost-effective care isn't dead -- but it's probably due for a re-brand. #valuebasedcare #cmmi #innovation

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Hospital Labor Expenses Escalate - What’s driving this escalation? In this Becker's Healthcare -Hospital Review article by Laura (Miller) Dyrda she reviews just released Kaufman Hall data on the ongoing labor expense escalation hospitals are facing nation-wide.   Reasons underlying these continued increases were not discussed in the resource article.   However, ONE major reason for this continued upwards pressure is the increasing shortfall of available workers to fill healthcare delivery positions.   Previous reports have point out that in healthcare – there are now inadequate numbers of workers in the pipeline (that includes doctors, nurses, and others) to fill open positions. Thus - increased retention costs to hold on to those who still remain – and are increasingly overworked!   This while the population bubble is increasing (Baby Boomers) and the NEED for more clinical healthcare workers is expanding!   ONE of the critical reasons for this increasing shortfall - is the continued EXODUS OUT of clinical healthcare by more and more doctors, mid-levels, nurses, and other ‘hands-on’ workers.   I again review reasons for the exodus in this recent post – link - https://lnkd.in/eknrZDUY   Labor (employee cost) is the single LARGEST expense for hospitals and other healthcare facilities. Increasing shortfalls in available workers - now coupled with an accelerating trend for our brightest young minds to increasingly choose non-healthcare delivery careers – if not reversed - hold OMINOUS implications for the future of healthcare delivery. American Medical Association American College of Emergency Physicians U.S. Senate Committee on Health, Education, Labor, & Pensions @Erik Swanson Scott Becker Cedric Dark, MD, MPH, FACEP Beth Kutscher American Hospital Association Clinician Burnout Foundation Jodie Green Denise Wiseman Tisha Titus, MD, MPH Nisha Mehta, MD America's Essential Hospitals Healthcare Reinvention Collaborative Interprofessional Primary Care Institute HDA - Healthcare Distribution Alliance Mehmet Oz Tradeoffs The Physicians Foundation The Conversation UK POLITICO World Economic Forum Doug Chesson Kelsey Fassold Cassie Shortsleeve Jeremy Corr Bill Cassidy https://lnkd.in/e3CsetAG

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Virtual care has the potential to democratize obesity treatment, but without clear principles, we risk repeating old mistakes with new tools.

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🚨 New CMMI model drop: ACCESS (Advancing Chronic Care with Effective, Scalable Solutions). This is one of the clearest signals yet that CMS is serious about scaling technology-supported chronic care in Original Medicare via outcome-aligned payments. A few early takeaways after an initial read: 📈 Big idea: recurring Outcome-Aligned Payments (OAPs) tied to measurable improvement/control (vs. paying for discrete activities/devices). 📊Initial clinical tracks are pragmatic and “volume ready”: early CKM (HTN/lipids/weight/A1c), CKM (diabetes/CKD/ASCVD), MSK chronic pain, and behavioral health (depression/anxiety). 📅 Timeline: model runs 10 years starting July 1, 2026; applications opening January 1, 2026. 🩺 Integration with primary care is baked in: co-management payment for coordination (with no copay!), required electronic updates to PCPs/referrals and HIE connectivity. What we’ll be watching for as CMS releases the Request for Applications / additional implementation detail: 💲 How OAP rates & risk adjustment are set (by track, severity, rurality, etc.) and how thresholds “ratchet” over time (especially after first year of enrollment during 'maintenance' period). ��� Measure definitions & guardrails: baseline capture, allowable data sources (claims vs. device vs. EHR), PRO requirements, and how CMS handles missingness/gaming. 🙋 Patient enrollment mechanics: referrals vs. self-enrollment, multi-track participation, disclosures, and operational impact of control group assignment for evaluation. ⚖️ Intersections with ACOs & other risk models: especially the stated transition where OAP spending begins to flow into ACO benchmarks/performance calculations starting 2028. ↔️ What this means beyond FFS: how payers may align using CMS-provided implementation resources, and what “ACCESS-like” looks like in MA/Medicaid contexts (no MA to start). 🧑‍💻 How will the non-Medicare enrolled tech-enabled health care providers participate - will they seek to enroll directly as a Part B provider/supplier or contract with existing entities? If you’re a provider, digital health org, MA plan, Medicaid leader, or ACO thinking about what performance based, tech-enabled care actually requires operationally—this model is worth a close read. Manatt Health will be publishing a full summary soon. Samantha Spear, Randi Seigel, Mandy Cohen, Christina Farr, Tom Cassels, Joshua Tauber, Amy Hunsberger https://lnkd.in/eKcZ3fPt

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New remote patient monitoring (RPM) codes proposed in the draft 2026 Medicare Physician Fee Schedule (PFS) are not yet finalized, the proposed rule and subsequent analyses have provided a detailed framework for how these services will be valued and reimbursed. Here is a detailed breakdown of the proposed fee structure for the new shorter monitoring periods, based on the information available in the draft rule released on July 14, 2025. Proposed New & Revised RPM CPT Codes for 2026 The draft rule introduces significant flexibility by unbundling the device and data transmission code (CPT 99454) and creating a new code for shorter monitoring periods. It also introduces a new code for shorter increments of clinical work.

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Here are four changes that matter to you and your hospital about the CMS 2026 hospital star ratings. The May 2026 Hospital Star Ratings update brings significant shifts that quality leaders need to understand now, before preview reports are released on February 19th. I just walked through the CMS presentation to pull out what actually matters for strategic planning: ✓ October 2025 Care Compare data confirmed as the basis (published in November) ✓ Bottom quartile safety domain penalty now live (expands in 2027) ✓ Hospital-Wide Mortality added to measure set ✓ Five new OAS CAHPS measures in Patient Experience CMS reports that almost half of hospitals will see a star change. 29% of hospitals will see an improvement and 18% will see a star drop. Preview reports available February 19th. Public release May 13th. To see their presentation and register for tomorrow's webinar: https://lnkd.in/emBZ28RF Questions on how these changes affect your hospital's rating? Post them in the comments.

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The physician practice landscape continues to shift — but not all specialties are moving at the same pace. L.E.K.’s Kevin Grabenstatter and Frazer Dorey provide a specialty-by-specialty view of where consolidation is accelerating, where it’s just beginning and how stakeholders can recalibrate strategies based on market maturity. https://bit.ly/45iVpRj #Healthcare #Strategy #PhysicianGroups #HealthSystems

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Price transparency marches on. HHS/DOL/Treasury, leveraging authorities under the ACA and certain ERISA modifications from the No Surprises Act, propose to update their 2020 rule for non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage. The proposed rule seeks to make data more useable while also reducing burden. Key provisions: Improved Machine-Readable File Requirements: requirements to organize In-network Rate Files by provider network instead of by plan or policy, which is intended to reduce file size, duplication, and make data more usable. Additional contextual files (e.g., Change-log, Utilization and Taxonomy) would be required to provide greater clarity and usability of the disclosed data. Expanded Data Elements: New data elements like product type (e.g., HMO or PPO), network name, enrollment counts, and exclusion of unlikely provider-to-service mappings would be added to improve the accuracy and context of pricing information. Reporting Frequency Changes: The reporting period for certain machine-readable files would shift from monthly to quarterly (except for prescription drug files), reducing administrative burden while maintaining up-to-date information. Lower Claims Thresholds & Longer Lookback Periods: For out-of-network allowed amount files, the threshold for including claims would decrease from 20 to 11 claims per item/service, with an increased reporting period from 90 days to 6 months and a lookback period extended from 180 days to 9 months. Reporting would also occur at the health insurance market level rather than at the plan/policy level. Enhanced Consumer Access: Cost-sharing estimates must be made available not only online but also via phone (using the number on insurance ID cards) and paper upon request. This satisfies requirements under section 114 of the No Surprises Act regarding price comparison tools. Future Standardization: The Departments are considering whether to indicate in either rulemaking or technical implementation guidance that the machine-readable files must be published in a single, nonproprietary, open-standards format, and, if so, naming either JavaScript Object Notation (JSON) or Comma Separate Value(s) (CSV) as that single format in technical implementation guidance. The Departments seek input from interested parties on such potential future rulemaking or technical implementation guidance. Special Aggregation Rules: Self-insured group health plans may allow third parties (such as TPAs) to aggregate data across multiple plans/networks when producing required disclosures under certain conditions, further reducing unnecessary duplication. https://lnkd.in/ercH4UNT

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Avalere Health's experts just published a quick analysis looking at specific health conditions that may see the biggest swing in risk adjustment payments under CMS's Part D proposal in the Advance Notice. Click to read more about the impact to cancer, diabetes, MS, and other conditions. https://lnkd.in/g4Key3Gt

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The CMS 2026 Proposed Rule is here—and it’s not just another policy update. It’s a signal of where value-based care is heading next. Expanded MVPs, tighter scoring rules, major interoperability mandates, and the potential sunset of traditional MIPS all point to a healthcare landscape that’s getting more data-driven, more outcomes-focused, and more complex. In our latest webinar, Senior VP of Product & Analytics Miranda Stork helps you decode the 2026 Proposed Rule and what it means for every stakeholder in the quality ecosystem. You’ll learn: - What CMS is prioritizing in 2026 - How MVPs will affect specialty reporting and payment pathways - How to align your internal processes before requirements become mandates If you’re responsible for regulatory strategy, quality performance, or clinical operations, this is one session you can’t afford to miss. Watch the full webinar on demand: https://hubs.ly/Q03Fkz0C0

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