Webinar - The Identity Disconnect: Bridging the Gap Between Data and Real-World Care Presented by Verato

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Featured Story   Healthcare’s AI Gold Rush…Is It Just Fool’s Gold? The skinny Healthcare is in the middle of an AI gold rush, with investors, providers and payers pouring more money than ever before into new technology. But according to a group of top healthcare CFOs and industry leaders gathered at HFMA's annual conference, much of that investment is destined to disappoint. The problem isn't necessarily the AI tools themselves — it's more that most healthcare organizations are bolting these sophisticated models onto infrastructure that is decades-old. Seema Verma, former CMS administrator and general manager of Oracle Health & Life Sciences, argued the infrastructure most providers are working with today is simply too antiquated to support what AI actually requires — namely, access to real-time, unified data across clinical, financial and operational systems. A formula for AI prioritization The demand for AI innovation already far outpaces any health system's ability to pay for it, which makes getting the foundational work right even more critical, noted Mike Marks, CFO of HCA Healthcare. His formula for prioritization is: clinical systems first, then operations and administrative functions. The logic is patient-centered. Clinical systems touch care delivery directly, so improvements there have the most immediate impact on health outcomes, Marks explained. Operations and administrative functions matter too, but in Marks' view, they should be optimized in service of a system that is already delivering high-quality care — rather than the other way around. Bot vs. bot BJC Healthcare CFO Scott Hawig said the current reality of healthcare AI is best captured by what's happening between payers and providers. He painted it like this: two sets of bots, each deployed by opposing sides, endlessly fighting over claims with no one winning. "Bot versus bot — provider revenue cycle bot against the denial insurance bot — is the fundamental problem," Hawig declared. — By Katie Adams Sponsored   Webinar - The Identity Disconnect: Bridging the Gap Between Data and Real-World Care Presented by Verato Join us on June 17th for a discussion on the hidden realities of healthcare interoperability. We’ll dive deep into the technical, organizational, and regulatory barriers making cross-network identity sharing so difficult. You’ll hear real-world examples of where identity mismatches go wrong, explore the massive impact of these gaps on Value-Based Care, and learn exactly how to build the business case for investing in identity-driven interoperability. Top Stories   OIG: 3 Largest MA Insurers Deny Prior Auth Requests at High Rates for Long-Term Acute Care, Inpatient Rehab The skinny A new report from the Office of Inspector General revealed that the three largest Medicare Advantage insurers denied prior authorization requests for long-term acute care and inpatient rehabilitation at high rates in 2024. OIG’s findings The analysis collected data from the 19 largest Medicare Advantage organizations for June 2024. It found that long-term care hospital (LTCH) denial rates were 80% in June 2024 for CVS Health, 72% for Humana and 71% for UnitedHealth Group, compared to 42% for all other MA organizations. Inpatient rehabilitation facility denial rates were 66% for UnitedHealth Group, 54% for Humana and 51% for CVS Health, versus 41% for other MA groups. When beneficiaries appealed denials, MA organizations overturned 36% of LTCH denials and 43% of inpatient rehabilitation denials. This indicates that “some enrollees were initially denied medically necessary care,” according to the report. The OIG also found that sometimes, high denial rates were due to contractors that denied prior authorization requests on behalf of MA organizations, and many were eventually overturned on appeal. — By Marissa Plescia FDA Wants This Drug Off the Market. Amgen Says Not So Fast. Dispute over a rare disease drug Amgen requested a hearing to challenge the FDA’s proposal to withdraw the approval of Tavneos, a drug developed to treat the rare disease ANCA-associated vasculitis. This drug came from Amgen’s $3.7 billion of acquisition of ChemoCentryx. In addition to safety risks associated with the drug, the FDA alleges manipulation of clinical trial data supporting Tavneos’s approval. The drug In ANCA-associated vasculitis, inflammation leads to damage of blood vessels and organs. The few treatments for this rare disease includes corticosteroids. While Tavneos does not replace steroids, it brings a different approach as an oral small molecule designed to inhibit the C5a receptor of the complement system, a part of the immune system. Why this matters Any manipulation of clinical data is a serious matter. But Amgen denies the FDA allegations and says the contract research organization that handled the pivotal trial only conducted prespecified procedures to “clean” the database to ensure it was accurate and complete. To support its position, Amgen has commissioned the Duke Clinical Research Institute to conduct an independent review of the Phase 3 data that supported Tavneos’s regulatory submission. This analysis and all other supporting material for the hearing are due by June 29. Soundbite “The Division Director did not know that the facts on which he was relying were untrue — that absent manipulation, the study results were not statistically significant on the superiority analysis at week 52, and the procedures in place to ensure trial quality were violated,” the FDA said in its proposal to withdraw Tavneos. “Had the Division Director known these facts, he would not have recommended approval." —By Frank Vinluan Reliable Transportation Isn’t a Luxury — It’s an Important Part of Cancer Care Transportation is key Access to healthcare providers is a significant factor in determining patient outcomes. Though not considered a breakthrough, transportation to lifesaving cancer treatment is a vital component of care for elderly, rural, low-income, uninsured, or underinsured cancer patients. National survey data suggests that about 3.1% of cancer survivors reported delaying care because of transportation barriers last year, representing roughly 476,000 Americans. Barriers cost lives Non-Emergency Medical Transportation (NEMT) provides access to critical cancer care for patients when they can’t drive themselves or don’t have public transportation options. Each ride has meaning. Each trip provides hope. Transportation barriers cost lives. Insecurity about transportation can lead to missed appointments and delayed care, and obstacles are more common for cancer patients than for the general population. This disparity contributes to higher numbers of emergency room visits and increased mortality rates. NEMT matters The NEMT industry has a role to play in making sure that every person with cancer — regardless of where they live or how they move — can arrive on time for the appointment they need. Because sometimes, the difference between life and death is not determined by complex clinical trials or invasive procedures; it’s whether someone can catch a ride. — By MedCity Influencer Darren Harline   Video   Video: Sen. Cassidy vs RFK Jr. Who won? In a Senate hearing, RFK Jr. cited 2 studies to show that mortality had reduced because of public health improvements not vaccines. Senator Cassidy's takedown is epic!

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