1/ I love reading the annual March MedPAC report to Congress on Medicare Payment Policy

such good, clear data and policy thinking.

kudos to @medicarepayment staff and chair @Michael_Chernew

I'll post some thoughts/highlights as I read through this morning 2/ My focus will be on the areas I know best
-Primary care
-Alternative payment models
-Medicare Advantage
-Competition and consolidation

The report is here for those following at home.

medpac.gov/document/march…

1/ After residency at Mass General Hospital, I reported to Atlanta to meet my fellow CDC Epidemic Intelligence Service Officers.

I have never felt so intimidated by my peers

The best and the brightest, they were star clinicians, had served in disaster zones; MD/PhDs and MSF. 2/ We were placed at various centers throughout CDC, learning from the world's experts- in tuberculosis, mosquito-borne diseases, food-borne diseases, ...

and some of us were placed with state & local Health departments to be on the front lines of outbreak response

1/ A topic of great interest at #JPM was the "better than expected" 2026 Advance Rate Notice for Medicare Advantage that dropped on Friday

I dug into the numbers - let me share what it might portend for plans and risk-taking providers in MA, after a tough couple of years

(🚀) 2/ I have to say I'm surprised how often investors/analysts believe that government actions are fundamentally arbitrary and unpredictable

I believe most agencies will tell you exactly what they're doing and why, if you have the patience to wade into the weeds

(me: a former fed)

1/ Is Value-Based Care working? After a decade, we know this:

The latest results for the largest such program just dropped.

Giving primary care accountability for total cost and quality of care is good for patients, good for practices, and good for society.

Let's dig in.

https://twitter.com/CMSGov/status/1851361393255080431

2/ As the press release says

480 ACOs providing care to nearly 11 million people with Medicare saved the gov't $5B dollars while improving quality of care

The gov't kept $2B

Providers earned an extra $3B

Beneficiaries saved on lower out-of-pocket spending-AND LESS SUFFERING

1/ The annual quick read and analysis of the Notice of Proposed Rulemaking that regulates the Medicare Shared Savings Program (MSSP) is upon us, folks.

like last year, there are a number of uncontroversial/incremental improvements

there are also a couple of head-scratchers..

https://twitter.com/Farzad_MD/status/1679656795214585856

2/ I will go through in roughly the same order as the excellent fact sheet:
cms.gov/newsroom/fact-…

and as usual, this builds on @Travis_Broome

x.com/Travis_Broome/…

1/ When Walmart enters any business you can expect that they will leverage their massive scale to get better economics, create value for customers- and drive out local mom and pop competitors

Thats what many assumed would happen w primary care clinics

but it didn't

why not? 2/ The first thing I have to acknowledge is to rule out "execution"

They aren't perfect (their Athena and Epic EMR travails show that) but Walmart knows how to execute, and they won't scale something until they've figured out how to make it profitable.

They couldn't

1/ The Change Healthcare cyber attacks have created perilous liquidity challenges for a substantial portion of US medical practices

This is not fine

We @AledadeACO are going to do whatever we can to help our affected partner practices- announcing $100M in advance payments today 2/ We were hoping UHG would step up and accept accountability for the cash flow faced by practices who relied on Change for submitting claims.

It is now clear that their program doesn't do this.

In this diagram, they seem to only cover costs when they are B, not A

1-5% of need

1/ Final rule for Physician Fee Schedule is out.

let's see how the Medicare Shared Savings Program provisions played out compared to the proposed rule.

(tl;dr mostly as proposed- incremental improvements to the nation's most mature, and most successful value based program)

https://twitter.com/Farzad_MD/status/1679656795214585856

2/ risk adjustment should be updated to the new "v28" approach for performance and benchmark years.

✅

my only complaint is that it's only applied moving forward- if it's good policy why not allow existing contracts to update?

https://twitter.com/Farzad_MD/status/1679658601986641922?t=eHG9Jpd4di8rPcGnSiQUTw&s=19

1/ What are the factors driving the mysterious slowdown in Medicare cost growth?

It's been a longstanding dinner conversation among health policy folks, and I have one idea to add to the mix that I haven't seen discussed yet.. 2/ There were lots of theories batted around in the article and the followup from @sangerkatz

My fav: "Talk Therapy Actually Works" (@ZekeEmanuel)

Policymakers setting expectations of cost control inhibit investments and behaviors that drive cost growth
nytimes.com/2023/09/09/ups…

1/ we set out to raise a $100M Series F. It would allow us to control our destiny- a lot of entrepreneurs claim (hope) "last funding round needed" but it really would be for @AledadeACO

In case you hadn't noticed tho, it's a pretty bad funding environment resources.aledade.com/press-releases… 2/ We had the full support of our existing investors (so key!) but many new investors were just "risk off"

They love the mission and love the company but are more concerned about downside risk than opportunities ahead rn

But true to their reputation, @lightspeedvp was different

1/ Warning!

nerdy Medicare payment deep dive

OMNIBUS EDITION

You've read the headlines ("Medicare pay cuts partially averted") but to understand what led us here--and what's to come-- we need to go deeper

Also, some cool tangents on effective/ineffective financial incentives 2/ let's walk through the weeds of

"a temporary patch on an expiring pandemic patch for the unintended consequences of a good-will effort to fix pay imbalance between primary care & specialists, made worse by a failure to predict future inflation, w a sop to value-based pay"

1/ Medical Debt- a holiday story

A few years ago, I found myself poring over a printout of ED frequent fliers with a PCP in Mississippi.

The office manager knew why they were going to the ED.

“They’re not going to show their faces here. They all owe us money.” 2/ Because of the Emergency Medical Treatment & Labor Act, the ED would see them even if they owed money

But thousands more dollars would have been added on top of the prior debts

His bills will climb. His credit score will drop. Collection agencies will start hounding him

1/ Let's flip through the Physician Fee Schedule Final Rule just out, w shared savings focus

Here's a little trick to get past all the pesky comments (that people spent 1000's of hours developing and submitting), and right to the meat of the matter:

CTRL-F "we are finalizing" 2/ First up: we want to increase participation!

strong evidence for providing upfront capital, especially to rural, underserved, low income ACOs (see AIM)

Good idea to expand it 👍

Lots of comments about eligibility criteria, repayment, etc etc.

"finalized as proposed"

1/ Medical practices (and staff) are often damaged by hurricanes too, and the need for care will rise over the next few days to weeks

I'll summarize here some tips that our @AledadeACO Louisiana team have assembled to help others w the recovery process

(eg grab your diplomas) 2/ The needs - and the damage to care capacity- can persist for weeks

“I’m trying to caution [residents]. You do not want to get hurt now. There is not adequate services to take care of you if you cut your leg with a chainsaw, if you fall off a roof,.."

https://twitter.com/Travis_Broome/status/1450168920456011787?s=20&t=OnqxAs78xO9ZC-2ljqBYOg

1/ there's been a lot of promise, but also disappointment in the influence of self-insured employers on improving the quality and cost of the healthcare they pay for.

I'm going to do a readout on what may go down as a seminal meeting last week

there's a big idea brewing..

https://twitter.com/PBGHealth/status/1570415333508349952

2/ first off, let's review the obvious.

*US healthcare relies overwhelmingly on employers to provide health insurance

*they aren't happy

*Many employer-led health reform efforts end in failure

(this is a good @commonwealthfnd summary of failures) commonwealthfund.org/blog/2021/no-s…

1/ One of the best parts of the CMS Medicare Shared Savings Program is the transparency

Hot off the presses: Independent practices working with @AledadeACO generated over $390M in savings for in this flagship value-based program...while increasing primary care access and quality

https://twitter.com/CMSGov/status/1564667170914803712

2/ There were 475 organizations in the program.

Getting savings is not easy.

Kudos to the physician groups with the highest savings rates in the country:

Top marks go to Aledade partner PMA in Pennsylvania.

Amazingly, the Mississippi COMMUNITY HEALTH CENTER ACO came in #4

1/ A year ago, there were a lot of healthcare tech companies valued on "top-line" revenue growth

That's no longer true.

So what's the right measure to value fast growing healthcare tech companies?

(thanks @BessemerVP @stephenkraus and @SofiaGuerraR) 2/ To some crusty traditionalists (and the newly minted value investors out there), it might be "bottom line" - EBITDA

But if I'm CEO of a company with great fundamentals and a huge market ahead of me, shouldn't I be investing now in future growth/profits (vs stockpiling cash)?

1/ How many times have we heard that newly minted doctors don't want to work in independent practice anymore?

("they don't want to work as hard, be practice owners")

We @AledadeACO are launching a program to support 20 PGY2 family medicine residents in proving that's nonsense 2/ We listened to what docs in training said were barriers-

*Residency training programs are hospital centric
*Few practice owner mentors/ role models
*Fewer financial supports/subsidies
*Less perceived opportunity for innovative practice models

We can solve for that!

1/ After 2 years of working hard to avoid getting-- and spreading-- COVID, the pandemic finally caught up with my family.

I thought I would share some of the things I learned along the way. 2/ *Infection*
Our behavior didn't change, but the virus did. As @ScottGottliebMD has noted- it sure seems like the most recent BA2 surge is increasingly hitting the remaining uninfected, who've been limiting social interactions, social distancing, masking

https://twitter.com/Farzad_MD/status/1471631913714688008?s=20&t=cRKCpnjsU7ZcI5gnnR_mnQ

1/ Jeff Zients was the right person to lead the US response when we faced unimaginable organizational challenges in getting a whole of government response into operations.

He and his team really did an admirable job, but communicating to the public was mostly Walensky and Fauci 2/ communicating to the public, in the midst of intense partisanship, evolving science, and evolving virus has been....difficult.

Fair or not, we have not had a single national credible, trusted spokesperson, managing public communications in a time of uncertainty (and anger)

1/ Would you want your employees, your customers, your partners, and government regulators to hear what you tell investors?

It's not done! Different audiences will understand and react to the same thing very differently

I'm going to take that risk today, show you my deck 😱🙏 2/ I'm going to walk through what I presented and said yesterday at the big healthcare investor meeting #JPMHC22

In a normal year, to hear the coveted private company presentations you'd have to be there, investors and executives crammed into small rooms

camera crews outside