Healthcare Financial Management

#Nationwide Employer Healthcare Strategy. Self-Funded nationwide employers are facing employee health plan budget problems. Healthcare costs are running unexpectedly high. These high healthcare costs are being driven by High Cost Claimants... the 5% of health plan members with high costs that drive 50% of overall health plan spending. Here are 5 #Strategies for Employers to Lower High Claimant Healthcare Costs: 1) #Network: Switch carriers to the only 1 out of the 4 major insurance carriers that has decent contracts with major hospital systems. 2) #ClaimsData: Get your claims data including allowed amount (and preferably Billed Charges, Provider NPI number and Provider Tax ID Number). Put your carrier out for RFP if necessary and include this data requirement in your RFP. 3) Engage #HighCost Claimants: Use the claims data to identify and assist existing high cost claimants and predict and prevent the most probable future high cost claimants. Use age greater than 50 as an initial screen for these potential high cost claimants. 4) Address Fraud, Waste and Abuse (#FWA): Use your claims data to identify fraudulent claims and prevent future payments to that same provider equal to the amount of the fraud. 5) #PBM: Carve-out your PBM to a transparent, pass-through PBM that DOES NOT require you to fill your specialty pharmacy medications through the mail order specialty pharmacy that they own. #EmployeeBenefits #HealthInsurance #Healthcare

For too long, Medicare Advantage has treated brokers as transactional middlemen. That misses their real value. At SCAN, we’re launching a new model that reframes brokers as health navigators—trusted partners who help members actually access care, not just choose a plan. As recently covered by Fierce Healthcare, this program equips brokers to support things that truly move the needle: -Welcome calls that drive early engagement -Annual wellness visits -Preventive care like flu shots -Ongoing navigation of the healthcare system And importantly — compensation tied to real health actions, not just enrollment volume. This is what value-based thinking should look like. If Medicare Advantage is going to justify its role as a public-private partnership, it has to deliver: -Better experiences -Better outcomes -Not just better marketing Brokers already sit at the center of trust in many communities. The opportunity is to align that trust with health. This is one small but meaningful step toward an MA ecosystem focused less on transactions and more on impact. https://lnkd.in/gHs7epR2

The ward was busy… until everything went silent." A nurse came to collect the prescribed medicines. She prepared them and began administration — just like hundreds of times before. Minutes later, the alarms started. Blood pressure dropping. Pulse slowing. Then — silence. --- Senior staff rushed in. The pharmacist arrived, quickly scanning the IV line and the drip. But it was too late. The patient was gone. --- What happened? The investigation revealed: During administration, Ceftriaxone had been mixed with Ringer’s Lactate — an incompatible combination. The reaction was unseen, but the result was deadly. --- What now? Beforehand, when the medicines were dispensed, the pharmacist had not given any guidance. No reminder. No warning. Just medicines. This wasn’t about skill — it was about knowledge. --- No doubt, nurses are irreplaceable in healthcare ; Experts in patient monitoring, procedures, injections, and quick action in emergencies. They carry the weight of bedside care every second. But when it comes to drug interactions and incompatibilities, the pharmacist is the specialist. Pharmacists are the last checkpoint for medication safety ; Experts in drug compatibility, interactions, and safe administration. Their words can stop an error before it starts. -- This case was not about blame. It was about a missing link in communication. Patient safety isn’t just about treatment — it’s about teamwork. Because in healthcare, silence can be fatal. When handing over medicines like Ceftriaxone, always guide: “Do NOT mix with Ringer’s Lactate.” Because sometimes, the most powerful tool in saving a life… is just a few seconds of conversation. What safety reminder could you give today that might save a life tomorrow? #Pharmacy #PatientSafety #MedicationSafety #ClinicalPharmacy #Nursing #DrugInteractions #PharmacistRole #HealthcareSafety

The US healthcare marketplace has no idea how to  value behavioral health interventions. And it's costing us everything. Here's what insurers are missing: ↳ Veterans getting mental health care show 40%   lower late-stage cancer rates ↳ Depression treatment cuts heart failure   rehospitalizations by 35% ↳ Anxiety therapy reduces all-cause mortality   in cardiac patients The math is staggering: 1/ Every $100 invested in behavioral health  ↳ Returns $190 in reduced medical claims ↳ Prevents costly emergency escalations ↳ Cuts inpatient hospitalization rates 2/ Mental health treatment for seniors ↳ Reduces dementia diagnosis rates significantly ↳ Particularly effective for vascular dementia ↳ Saves decades of long-term care costs 3/ Employer programs prove the ROI ↳ Telepsychiatry shows comparable total costs ↳ Outpatient interventions prevent crises ↳ Early screening stops illness progression Yet insurers still treat mental health as  "nice to have" instead of "must have." This isn't just about parity laws. It's about basic healthcare economics. When we underpay for behavioral health, we  overpay for everything else. Mental health treatment doesn't just save minds. It saves lives, money, and entire healthcare systems. ------------------------------------------- ⁉️ How much longer can we afford to ignore  the $190 return on every $100 invested? ♻️ Share if you believe behavioral healthcare is mispriced. 👉 Follow me for more (Eric Arzubi, MD).

This morning, I wrote about the rising cost of health coverage for employers -- surveys and benefits consultants are predicting increases of 9% or more for next year, the largest jumps in at least 15 years. And that would come on top of rapid growth over the last two years. The spike is driven by rising healthcare costs, with factors including higher prices for hospital services, more use of care by a population with rising incidence of conditions including cancer, and pricey drugs including the GLP-1s. One thing that struck me in the benefits consultant surveys, and in my interviews with employers, was their increased willingness to look at more-radical changes. That could include new types of plan designs that could incorporate restrictions on access to some healthcare providers, eyeing smaller vendors that compete with the big insurer/PBM companies, or, in the case of one company I interviewed, the possibility of moving to another country where healthcare is backed by the government, not private employers. As one source said, there seemed to be a mix of emotions from employers, from freaked-out, to resigned, to deeply frustrated that the cost of health coverage was rising so much faster than the prices they could charge for their own goods and services. However, I've been covering this beat for many years, and I've always found that employers tend to be pretty cautious and reluctant to make huge changes -- for good reason, since healthcare is so important to many workers, and disrupting access often draws enormous backlash. So when employers do make changes, it's often a slightly different flavor of what they were already doing. What do you think? Are significant numbers of employers ready to try something different? And, if so, what would that be?

🎉 Pleased to share our paper published in Nature Portfolio digital medicine. 🥳 We’ve developed a comprehensive framework called CREOLA (short for Clinical Review Of Large Language Models (LLMs) and AI). This framework is pioneered at TORTUS, taking a safety-first, science approach to LLMs in healthcare. 🔹 Key Components of the CREOLA Framework -Error Taxonomy -Clinical Safety Assessment -Iterative Experimental Structure 🔹 Error Taxonomy Hallucinations: instances of text in clinical documents unsupported by the transcript of the clinical encounter Omissions: Clinically important text in the encounter that was not included in the clinical documentation 🔹 Clinical Safety Assessment: Our innovation incorporates accepted clinical hazard identification principles (based on NHS DCB0129 standards) to evaluate the potential harm of errors: We categorise errors as either ‘major’ or ‘minor’, where major errors can have downstream impact on the diagnosis or the management of the patient if left uncorrected.  This is further assessed as a risk matrix comprising of: Risk severity (1 (minor) to 5 (catastrophic)) compared with Likelihood assessment (very low to very high) 🔹 Iterative Experimental Structure We share a methodical approach to compare different prompts, models, and workflows. Label errors, consolidate review, evaluate clinical safety (and then make further adjustments and re-evaluate if necessary). ----------Method-------------- To demonstrate how to apply CREOLA to any LLM / AVT, we used GPT-4 (early 2024) as a case study here. 🔹 We conduct one of the largest manual evaluations of LLM-generated clinical notes to date, analyzing 49,590 transcript sentences and 12,999 clinical note sentences across 18 experimental configurations. 🔹 Transcripts-clinical note pairs are broken down to a sentence level and annotated for errors by clinicians. ----------Results-------------- 🔹 Of 12,999 sentences in 450 clinical notes, 191 sentences had hallucinations (1.47%), of which 84 sentences (44%) were major. Of the 49,590 sentences from our consultation transcripts, 1712 sentences were omitted (3.45%), of which 286 (16.7%) of which were classified as major and 1426 (83.3%) as minor. 🔹 Hallucination types Fabrication (43%) - completely invented information Negation (30%) - contradicting clinical facts Contextual (17%) - mixing unrelated topics Causality (10%) - speculating on causes without evidence 🔹 Hallucinations, while less common than omissions, carry significantly more clinical risk. Negation hallucinations were the most concerning 🔹 we CAN reduce or even abolish hallucinations and omissions by making prompt or model changes. In one experiment with GPT4 - We reduced incidence of major hallucinations by 75%, major omissions by 58%, and minor omissions by 35% through prompt iteration Links in comments Ellie Asgari Nina Montaña Brown Magda Dubois Saleh Khalil Jasmine Balloch Dr Dom Pimenta M.D.

No one who actually works in healthcare is shocked by the The Wall Street Journal story about UnitedHealth Group's CEO making private investments in healthcare startups. Not the undisclosed investments. Not the affiliated entities. Not even the emails suggesting certain involvement was better kept out of writing, but could be communicated "verbally." Anyone who has spent time in this business knows none of this requires much imagination. Dinner and drinks with a payer executive, a startup CEO whose model depends on coverage expansion, a private equity sponsor looking for scale, and a policymaker in the room; all talking about where reimbursement is going, what policies are likely to move, which services are about to become “standard of care,” and what that means for business. They don't whisper. Its not a conspiracy. Just people with aligned incentives discussing the future of the market. There are so many versions of this dinner. Hospital mergers announced alongside extraordinary exit packages for retiring executives, sold as expanded access and efficiency. Coverage expansions framed as breakthroughs for patients that also happen to align perfectly with existing investments. Startups that succeed or fail based on access to distribution, reimbursement, or the right strategic relationship rather than clinical value. Walk someone through how healthcare business actually gets done - how access to the market is controlled, how claims move through layers of intermediaries taking their cut, how companies that call themselves competitors work together in order to keep the economics working. There’s usually a moment where they say, "Surely, this can' be legal?!" Its not, not legal. But when you hear it described plainly, it often sounds like it should be. UnitedHealth Group's Hemsley recently testified before Congress that his company's most important goal is to make healthcare "more accessible and more affordable."  He is now worth nearly a billion dollars, wealth built almost entirely from this company and this industry. I’m not opposed to people succeeding. But at some point we should be honest about what success in this industry reflects. It is rarely the result of making care more accessible or affordable. More often, it comes from understanding how the system works and benefiting from the complexity itself. Call it a market if you want. Many people who work inside it would use a different word. Peter HayesJustin LeaderPreston AlexanderShawn GremmingerCora OpsahlDoug AldeenMarsha SimonMarilyn BartlettJulia PosackiJulie SelesnickLee LewisNelson GriswoldAshleigh Gunter Thomas CampanellaGe BaiVivian HoJohn TozziPatient Rights Advocate https://lnkd.in/erk2kBPN

18-20% annual increase - that's the rate at which healthcare costs are rising. It's a number that should make every business leader pause and think. This surge in healthcare expenses isn't making headlines, yet it's a critical issue that's slowly eroding the value of our employee health insurance plans. If we're not increasing our Group Health Insurance (GHI) coverage every three years, we're effectively reducing our employees' health protection. Here's why: ➤ Technological Leap: The medical field is transforming. We've moved from X-rays to MRIs in what feels like a blink, and each leap brings better care but at a premium. ➤ Facility Upgrades: Even smaller hospitals now feature cutting-edge equipment, driving up expenses. ➤ Pharmaceutical Costs: New, life-saving drugs enter the market at high prices due to extensive R&D investments. ➤ Operational Expenses: Rising real estate costs for medical facilities and competitive salaries for healthcare professionals contribute to overall cost increases. The math is simple. Over three years, we're looking at a 50-60% increase in healthcare costs. Our GHI plans need to keep pace, or we're shortchanging our teams. I've seen the consequences firsthand: Employees facing crippling medical debts. Delayed treatments due to coverage gaps. Stress that impacts not just health, but productivity and loyalty. The solution isn't complex, but it requires commitment: ➤ Audit your GHI plans annually. ➤ Increase coverage limits every three years, aiming for at least a 50% bump. ➤ Educate your team on their coverage – awareness is half the battle. ➤ Partner with insurers who understand this new landscape. As leaders, we don't just manage businesses – we safeguard our people. In this era of skyrocketing healthcare costs, that means taking a hard look at our GHI plans and making sure they're not just good on paper, but good in practice. It's about that woman in operations who beat cancer without bankrupting her family, or the guy in IT whose child got the specialty care they needed. The companies that act now will set the standard for employee care in the years to come. The question is: Will you be one of them? #PolicybazaarforBusiness #HealthcareCrisis #Employeebenefit #grouphealthinsurance

Private equity is rapidly expanding into healthcare, but how does this affect which patients get care? Our new research letter in JAMA Network Open tackled this question by studying ophthalmology practices acquired by PE firms. The surprising finding: While patient visits increased across all insurance types after PE acquisition, the proportion of patients actually shifted toward Medicare and away from commercial insurance. This could mean commercial insurers are avoiding PE-backed practices, or that these practices want to retain Medicare FFS patients for stable reimbursement rates. Either way, it challenges assumptions about PE prioritizing only the highest-paying patients. As private equity's healthcare presence grows, we must continue to look at how it affects both access and quality. Read the full research letter, linked in the comments. #HealthcareonLinkedIn #PrivateEquityinHealthcare

Caring for aging parents is a challenge many don’t see coming. It can get overwhelming fast. Are you ready? I see it all the time—families blindsided by how quickly those responsibilities show up. And trust me, the financial hit is real. Assisted living can run over $70,000 a year, and memory care? Easily $90,000 annually. So, how do you prepare for something so overwhelming? Here’s what I tell my clients: ➡️ Talk now, not later. Have the tough talk with your parents. Ask about their care wishes and whether they have assets or insurance. The sooner you know, the better you can plan. ➡️ Don’t wait—explore options today. Visit facilities, compare home care, and nail down the costs now. Scrambling in a crisis is the last thing you want. ➡️ Stay financially flexible. Medical and care costs are wild cards. Make sure your plan can handle the unexpected with savings, insurance, or other strategies. And if you’re dealing with this now, protect yourself. In your 50s? Look into long-term care insurance—especially if self-insuring isn’t an option. It’s a smart move, whether you have kids or not. It’s about peace of mind and ensuring you don’t pass the burden onto others. Planning today means less stress tomorrow. Let’s make sure you’re ready. —— P.S. Want to see how long your current assets might last when it comes to long-term care? Use the calculator in the comments.