Brandon Charles MD

This qualitative study interviewed 81 C- and D-suite decision makers from payers, providers, PBMs, IDNs, and pharmacies to explore how notions of “quality” influence transactions across the healthcare ecosystem. While formal metrics (HEDIS, CAHPS, etc.) are part of the calculus, respondents emphasized that 𝘃𝗮𝗹𝘂𝗲, 𝗿𝗲𝗽𝘂𝘁𝗮𝘁𝗶𝗼𝗻, 𝘁𝗿𝘂𝘀𝘁, 𝗰𝘂𝗹𝘁𝘂𝗿𝗮𝗹 𝗮𝗹𝗶𝗴𝗻𝗺𝗲𝗻𝘁, 𝗮𝗻𝗱 𝗳𝗶𝗻𝗮𝗻𝗰𝗶𝗮𝗹 𝗥𝗢𝗜 𝗳𝗿𝗲𝗾𝘂𝗲𝗻𝘁𝗹𝘆 𝗼𝘂𝘁𝘄𝗲𝗶𝗴𝗵 𝗿𝗮𝘄 𝗾𝘂𝗮𝗹𝗶𝘁𝘆 𝘀𝗰𝗼𝗿𝗲𝘀 𝘄𝗵𝗲𝗻 𝗰𝗵𝗼𝗼𝘀𝗶𝗻𝗴 𝗼𝗿 𝘀𝘂𝘀𝘁𝗮𝗶𝗻𝗶𝗻𝗴 𝗽𝗮𝗿𝘁𝗻𝗲𝗿𝘀𝗵𝗶𝗽𝘀. Over a relationship’s life cycle (initiation → continuation → termination), decision makers continually reassess whether the partner delivers on those broader drivers, not just narrow quality metrics. The take-home for executives: 𝘪𝘧 𝘺𝘰𝘶𝘳 𝘲𝘶𝘢𝘭𝘪𝘵𝘺 𝘱𝘳𝘰𝘨𝘳𝘢𝘮 𝘪𝘴 𝘥𝘦𝘤𝘰𝘶𝘱𝘭𝘦𝘥 𝘧𝘳𝘰𝘮 𝘱𝘦𝘳𝘤𝘦𝘪𝘷𝘦𝘥 𝘷𝘢𝘭𝘶𝘦, 𝘵𝘳𝘶𝘴𝘵, 𝘢𝘯𝘥 𝘴𝘵𝘳𝘢𝘵𝘦𝘨𝘪𝘤 𝘢𝘭𝘪𝘨𝘯𝘮𝘦𝘯𝘵, 𝘪𝘵 𝘸𝘪𝘭𝘭 𝘴𝘵𝘳𝘶𝘨𝘨𝘭𝘦 𝘵𝘰 𝘪𝘯𝘧𝘭𝘶𝘦𝘯𝘤𝘦 𝘳𝘦𝘢𝘭 𝘣𝘶𝘴𝘪𝘯𝘦𝘴𝘴 𝘵𝘳𝘢𝘯𝘴𝘢𝘤𝘵𝘪𝘰𝘯𝘴. You’ll need to embed quality into your relational and commercial narrative, not just your compliance footprint. Action items for execs and physician leaders: 🔍 𝗥𝗲𝗳𝗿𝗮𝗺𝗲 “𝗾𝘂𝗮𝗹𝗶𝘁𝘆” 𝗶𝗻𝘁𝗲𝗿𝗻𝗮𝗹𝗹𝘆 𝗮𝗻𝗱 𝗲𝘅𝘁𝗲𝗿𝗻𝗮𝗹𝗹𝘆 𝘁𝗼 𝗶𝗻𝗰𝗹𝘂𝗱𝗲 𝘃𝗮𝗹𝘂𝗲, 𝘁𝗿𝘂𝘀𝘁, 𝗮𝗻𝗱 𝘀𝘁𝗿𝗮𝘁𝗲𝗴𝗶𝗰 𝗳𝗶𝘁, not just metric scores 🤝 𝗔𝘂𝗱𝗶𝘁 𝘆𝗼𝘂𝗿 𝗽𝗮𝗿𝘁𝗻𝗲𝗿 𝗰𝗼𝗻𝘁𝗿𝗮𝗰𝘁𝘀 to see where reputation, alignment, or innovation clauses could hold more sway 📊 𝗨𝘀𝗲 “𝗵𝗲𝗮𝗹𝘁𝗵 𝗼𝗳 𝗿𝗲𝗹𝗮𝘁𝗶𝗼𝗻𝘀𝗵𝗶𝗽” 𝗱𝗮𝘀𝗵𝗯𝗼𝗮𝗿𝗱𝘀 (beyond quality metrics) to monitor partnerships and flag early strain 🚦 𝗕𝗲 𝗱𝗲𝗹𝗶𝗯𝗲𝗿𝗮𝘁𝗲 𝗮𝗯𝗼𝘂𝘁 𝘁𝗲𝗿𝗺𝗶𝗻𝗮𝘁𝗶𝗼𝗻 𝘁𝗿𝗶𝗴𝗴𝗲𝗿𝘀: don’t wait for catastrophic failure to pull the plug

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CMS just proposed a 0.09% Medicare Advantage rate increase for 2027. Wall Street expected 4-6%. Humana dropped 13%. UnitedHealth fell 9%. CVS down 9%. The era of MA as a margin expansion vehicle is ending. CMS is signaling that plans need to deliver value to members, not just shareholders. If plans respond by cutting benefits or exiting markets, seniors lose. If plans respond by finally fixing operational inefficiencies, everyone wins. The next few months will reveal which path the industry chooses. Insurers have been running the same playbook for years. Negotiate rates, manage utilization, expand membership. That playbook assumed steady rate increases would cover rising costs but the math breaks with rates essentially flat. The plans that don't adapt will either exit MA or get acquired by those who did. Last year's 5.06% increase masked structural problems. This year's 0.09% exposes them. Health plan leaders watching this should be asking: Are we built to deliver value at these margins, or were we built for a different era?

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Your AI denial rate is now a $100M board liability. Most health plan CTOs still don't know their number. That changes this week — or it should. Here is what CMS just did: The 2027 Star Rating methodology now flags AI-assisted prior auth denial rates more than two standard deviations above the mean. For plans with 500,000+ members, a single star rating drop costs more than $100M annually in lost quality bonus payments. Your AI denial rate just became a revenue number. The Senate Permanent Subcommittee on Investigations spent two years and 280,000 pages of internal insurer documents reaching one conclusion: AI-assisted denial rates ran up to 16 times higher than human review rates at the nation's largest Medicare Advantage plans. CMS read that report. They are now building it into the methodology that determines your bonus payments. I have audited AI denial rate variance across multiple Medicare Advantage plans. The performance gap between best and worst performers is not model quality. It is not vendor selection. It is not data infrastructure. It is whether anyone is reviewing what the model produces after it fires. Detection is not the finish line. Governance is. Here is where to start — this week, not next quarter: 1. Pull your AI vs. human prior auth denial rate split in the next 24 hours. If you cannot retrieve it in 24 hours, your audit trail is already a CMS liability — not a future risk, a current one. 2. Map every denial above the CMS mean to a model version and a clinical policy date. Do this before Q2. The plans that cannot do this are the plans that will be explaining star rating drops to their boards in 2027. 3. Brief your board audit committee on AI denial variance before this month ends. This is not an IT agenda item. It is a fiduciary one. The Senate report made it one. CMS made it one. Your board just does not know it yet. Stanford researchers publishing in Health Affairs this January put it plainly: The central risk in AI prior authorization is not the algorithm. It is the absence of meaningful human review after the algorithm fires. That gap — between model output and clinical accountability — is where $100M star rating exposure lives. And right now, most plans cannot even measure it. Health plan CMOs and CTOs: Do you know your AI denial rate versus your human review rate — right now? Yes or No. Answer below. Your answer tells me more about your plan's 2027 star rating exposure than any dashboard will. #MedicareAdvantage #HealthcareAI #StarRatings #AIGovernance #BoardLeadership #HealthcareVC

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As many folks head to Dallas this week for the Healthcare Financial Management Association (HFMA) Revenue Cycle Conference, I’m excited to share news that marks another step forward as we continue the investment in Knowtion Health and its future serving health systems across the country get paid appropriately for the services they provide. We’ve completed the acquisition of revly, founded and led by Bennett Holden, expanding our claim routing service offering. Our combined offering is now the most comprehensive (PB + HB) and EMR agnostic solution in the market. We are committed to intentionally adding specific verticals to help revenue cycle leaders solve specific complex problems coupled with best in KLAS Research customer service. On behalf of all of my teammates, we couldn’t be more excited about the future of Knowtion Health! You can read more about the announcement here-> https://lnkd.in/guwYbhCb

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