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Kevin Thilborger shared thisI feel like “approved” should be a fairly definitive word. Imagine getting approved for a $40,000 car loan, buying the car, and then having the bank decide six months later that it only approved $35,000 after all. A version of that is happening in healthcare, where “approved” has become more of a temporary condition than an agreement to pay for an authorized service at the negotiated rate. A payor approves the authorization but then downcodes the claim or reduces the payment... or recoups the money after they've reviewed and decided they overpaid. You know things have gotten strange when Congress is considering legislation to make Medicare Advantage approvals harder to undo. Imagine needing a federal law to make “approved” mean approved. It got me thinking about a bigger question. If revenue you thought was settled can become unsettled again, what is your managed care contract actually worth? More here: https://hubs.li/Q04yrN2F0
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Kevin Thilborger shared thisIf healthcare premiums are the problem, why aren't we talking about insurer profits? Median household income in America is about $84,000 and the average employer-sponsored family health insurance policy now costs nearly $27,000 a year. States are understandably sounding alarms about healthcare affordability. A recent Health Affairs Forefront article describes a growing list of state efforts to control costs. Their answer seems to be, in many cases, pay hospitals less. Interesting choice given hospitals are less and less of the total cost of care. If states cut hospital payments, show us what happens next. Do premiums fall? Do deductibles fall? How much of the savings reaches families? Or does the insurer simply spend less on medical care? Payor advocates have spent years making hospitals the face of healthcare affordability. Payment caps like these suggest they've been remarkably successful. Winning the contract negotiation while losing the larger argument about who bears responsibility for affordability is not much of a victory. The payors are making their case in statehouses across the country. Hospitals need to match their intensity. What are your plans?
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Kevin Thilborger shared thisThis will be interesting to watch - will Walmart and SCAN be able to use all the data to drive overall health and taxpayer savings?? #medicareadvantage #insightsSCAN Health Plan, Walmart partner on Medicare Advantage plansSCAN Health Plan, Walmart partner on Medicare Advantage plans
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Kevin Thilborger shared thisPayors have been promising prior authorization reform for years, but we’ve yet to see meaningful change. For those of us who live and breathe this issue, the payor promises seem empty, and the legislative efforts, while well-meaning, have been fairly toothless. Payors like to describe utilization management as ensuring the right care, at the right time, in the right place. Increasingly, it seems to be about the right place — on the balance sheet — at the right time — for quarterly reporting. I’m watching the reforms Massachusetts is attempting to achieve. How will payors respond? And what will the end result be for providers and patients?That’s what I’m digging into in my latest article. Providers, do you know what prior authorization is actually costing your organization? More importantly, do you know what the delays are costing your patients in terms of their health outcomes? If we don’t measure those things, how will we know whether reform actually worked? https://hubs.li/Q04xtSJ70
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Kevin Thilborger shared thisExceptionally important part of the overall patient impression of your healthcare organizationKevin Thilborger shared thisWhere a health system invests, where it expands, who it recruits, and how it treats patients all shape what people believe about the organization. Those decisions build reputation long before anyone needs a communications strategy to protect it. Michael Petrone, Senior Director of Strategic Communications at Unlock Health, looks at how health systems can make reputation an enterprise asset they build deliberately every day. Read more: https://hubs.li/Q04wXWqZ0
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Kevin Thilborger shared thisThe federal government expected about 22,000 No Surprises Act payment disputes in the first year. We’re past 5 million, and providers are winning about 85% of the decisions. Payors are not taking it particularly well. There’s a lot to unpack here — including what IDR is doing to network economics, reimbursement negotiations, and the healthcare cost narrative. That’s exactly what I do in my latest article: https://hubs.li/Q04v-DVn0 Provider leaders: Payors are paying attention to what IDR is doing to reimbursement. Are you using the same data when you negotiate your in-network rates?
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Kevin Thilborger shared thisA respected annual survey of large employers came out recently, and health system leaders should pay attention to what employers think is driving their healthcare costs. Because increasingly, they think it’s hospitals. In fact, 62% say hospital price increases are driving healthcare costs to a great or very great extent. Health systems should address this perception. But first, ask yourself a question. Who have employers been hearing from? For years, health plans, brokers, consultants, policymakers, and well-funded (by agenda-driven billionaires) advocacy groups have been blaming health systems. Health systems and physicians have mostly stayed quiet. Meanwhile, labor costs, drug costs, and technology costs increased dramatically. Medicare and Medicaid insurers continued paying below the cost of care. Administrative requirements multiplied, denials increased, and prior authorization expanded. And health systems kept funding emergency departments, trauma programs, specialty care, and all the other infrastructure communities expect to be there when they need it. Health system leaders know all of that. Do employers and brokers? Employers are increasingly making purchasing decisions based on what they believe is driving their healthcare spend. They're expanding centers of excellence, high-performance networks, alternative health plans, care navigation, and other strategies that can direct employees toward specific providers and sites of care. Employers should understand what commercial reimbursement actually pays for: access, clinical capacity, expensive services that communities depend on, and the infrastructure required to provide care 24/7. They also need to show the value employers receive through outcomes, access, total cost of care, and workforce impact. Silence allows the narrative to be set by others. And employers now have the tools to act on the answers they're getting. So, what are you going to do about it? Are you going to keep silent and allow others to set the discussion? Or are you going to make sure patients and employers understand your economics, your value, and what their employees stand to lose when purchasing decisions are based on only half the story?
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Kevin Thilborger posted thisCalifornia has a plan to make healthcare more affordable. The state will tell hospitals how quickly their spending should grow and let them figure out the rest. Office of Health Care Affordability (OHCA) has set a statewide healthcare spending-growth target of 3.5% per person for 2026, eventually falling to 3%. Tomorrow, OHCA votes on key elements of the enforcement framework, including the scope and range of financial penalties that could ultimately apply to hospitals, physician organizations, health plans, and integrated delivery systems that exceed their targets. California is generously allowing hospitals to figure out for themselves how to keep spending growth below the target. That should be especially fun in one of the most expensive states in the country. Hospitals have to recruit and retain people who can actually afford to live there, maintain facilities, and adhere to earthquake standards. And OHCA doesnt control the cost of drugs and tech. Want to recruit a nationally recognized physician, expand a service line, increase capacity, or invest in a promising new treatment? Go right ahead but you may have to outsource jobs to India and Costa Rica for billing and customer service. Healthcare affordability is a serious problem. But there’s no line on a hospital income statement called “unnecessary spending” that you can conveniently reduce until you hit 3.5%. Choices will have to be made. There's probably some genuine waste to root out but spending and job creation will slow. California itself describes its law as providing stronger enforcement authority than other state healthcare spending programs, with progressive enforcement that can lead to financial penalties. Politically, putting a hard number on spending growth and penalties behind it certainly looks like action. So if you lead a hospital or health system outside California, I’d be asking a different question. What is your state up to? Spending-growth targets already exist in other states In fact, the debate over California’s penalty structure has explicitly compared its approach with Massachusetts and Oregon. If there’s any chance your governor, legislature, or regulators might decide a healthcare spending cap sounds appealing, the time to build your advocacy strategy is before policymakers put a proposal on the table. Explain your economics. Show where your costs are actually going. Quantify what your organization is investing in access, workforce, technology, and services your community depends on. Because once policymakers have decided that 3.5% sounds like the right answer, it’s too late.
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Kevin Thilborger shared thisUnlike many vertically integrated payors, Kaiser has spent decades operating a model that directly links health coverage with care delivery through its health plan, hospitals, and Permanente Medical Groups. That makes its results an interesting look at the economics of integration and value-based care. The consolidated results also include Risant Health, so they aren’t a pure readout of Kaiser’s traditional model. Q1 wasn’t the best. Revenue increased, but operating income fell from $932 million to $711 million and operating margin declined from 2.9% to 2.1%. Care delivery costs remained elevated, but Kaiser also incurred additional one-time costs related to work stoppages. Q2 looks a whole lot better. Revenue increased 10.9% to $35.6 billion. Operating income jumped 61% from $1.03 billion to $1.66 billion, and operating margin improved from 3.2% to 4.6%. Investment returns pushed net income to $5.3 billion, but the operating improvement is the number we're watching. Kaiser says disciplined operations and using its size and scale to create back-end efficiencies helped improve affordability. I'd love to know more about those efficiencies. Is Kaiser starting to get more leverage from its scale? Are technology investments paying off? Is integration helping manage utilization and move care into more appropriate settings? That's especially interesting because Kaiser is trying to extend elements of the model. Risant now includes Geisinger and Cone Health, giving Kaiser a way to bring its value-based capabilities to established health systems that weren't built like Kaiser. In northern Nevada, Kaiser is taking a different approach with Renown Health. The two jointly own Hometown Health, while Kaiser is building out physicians, outpatient care and its digital platform. Members will rely on Renown for hospital services and will continue to have access to its specialty services when new coverage options begin in 2027. Kaiser is essentially testing how much of its integrated model can travel. Plenty of companies have spent billions buying pieces of the healthcare system and calling it integration. Kaiser has spent decades actually operating an integrated financing and delivery model. Risant and Renown may tell us whether some of what makes that model work can be replicated without rebuilding Kaiser from scratch. For health systems, the more interesting question is what happens if Kaiser proves it can export the model. What could you build yourself, and what would you be better off getting through an alignment with an organization like Risant?
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Barry, just wrote a similar piece
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Kevin Thilborger reacted on thisKevin Thilborger reacted on thisA new chapter begins at Lee Health! 💙 Today, we officially welcome Ben Spence into his new role as President and Chief Executive Officer of Lee Health. Ben has dedicated more than 30 years to Lee Health, serving in leadership roles across finance, strategy, and operations while helping shape the organization we are today. Now, he begins his next chapter leading Lee Health forward and continuing our commitment to serving the people of Southwest Florida. Please join us in congratulating Ben and welcoming him on his first day as President and CEO! 👏 #LeeHealth #Leadership #SouthwestFlorida
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Kevin Thilborger liked thisKevin Thilborger liked thisI’m thrilled to join Strive Health as Chief Network & Engagement Officer and help strengthen the provider partnerships and patient connections that support better kidney care. I look forward to working alongside Strive’s new Chief Operating Officer Susan Ray, Chief Growth Officer Dan Heslin and the entire Strive team. Together, we’ll build on Strive’s momentum, deepen engagement across its national provider network and expand access to care for more people living with kidney disease. Learn more: https://lnkd.in/eM8iU-vv #KidneyCare #ValueBasedCare #HealthcareLeadershipStrive Health Expands Executive Team to Support Next Phase of Growth - Strive HealthStrive Health Expands Executive Team to Support Next Phase of Growth - Strive Health
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Kevin Thilborger liked thisI feel like “approved” should be a fairly definitive word. Imagine getting approved for a $40,000 car loan, buying the car, and then having the bank decide six months later that it only approved $35,000 after all. A version of that is happening in healthcare, where “approved” has become more of a temporary condition than an agreement to pay for an authorized service at the negotiated rate. A payor approves the authorization but then downcodes the claim or reduces the payment... or recoups the money after they've reviewed and decided they overpaid. You know things have gotten strange when Congress is considering legislation to make Medicare Advantage approvals harder to undo. Imagine needing a federal law to make “approved” mean approved. It got me thinking about a bigger question. If revenue you thought was settled can become unsettled again, what is your managed care contract actually worth? More here: https://hubs.li/Q04yrN2F0
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Kevin Thilborger liked thisKevin Thilborger liked thisJust a couple of photos from "The seven deadly sins of healthcare marketing (and how to repent before your audience leaves you behind). We had so much fun with this session. Thanks to Dan Lavelle and Christian Barnett for being such good sports and even going all in with costumes. If you were at the session, we'd love to hear from you! #SHSMD26
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