Wes Roach

Everyone is talking about the Home Health Final Rule rate update—but don’t overlook the big shift happening inside HHVBP. Once again, CMS has changed the rules for home health agencies. Why? Because they uncovered a flaw in the program’s design. As the chart below illustrates, the majority of agencies (71%) that earned a 5% increase for CY 2025 didn’t have HHCAHPS scores. In other words, we ended up rewarding agencies for not having data—and giving lower adjustments to those with more to manage. To respond, CMS changed the HHCAHPS measurements. But the issue isn’t what we’re measuring. The real problem is how CMS defines large vs. small cohorts. It's as simple as this: Agencies without CAHPS scores should not be compared to those who have them. Cohorts should be defined not by who is CAHPS eligible, but who has CAHPS data.

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Health insurers initially deny ~11% of providers' claims, require prior authorization before expensive procedures, and increasingly are downcoding providers' E+M codes to reimburse them less. Why? What we emphasize in our "How to Speak Insurer" strategy bootcamp: like any two-sided marketplace, insurers must balance the needs of both sides of the platform. To attract providers to their networks, insurers must be able to offer volume ("we have so many members on our plans that you'll never have an empty appointment slot") or better reimbursement rates and fewer denials ("we don't have a ton of members, but we'll pay you well when you see them and won't deny claims aggressively"). But insurers are not the ultimate purchasers of healthcare services. That's government ($2.5T), households ($1.5T) and employers ($1T). Insurers typically retain ~7% of premiums to cover their own operations and shareholders' profit expectations...so in order to pay more to providers they must raise premiums. And these purchasers will simply not select a given insurer if it's premiums are too high. This is the unfavorable PR position that insurers find themselves in, and a key area for diplomacy when speaking with insurers.

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Most Medicaid debates focus on coverage, how to expand it, manage it, or contain its costs. Far less attention goes to preventing people from needing it in the first place. The Healthy Opportunities Pilot (HOP) in North Carolina offered one of the most promising examples of this upstream approach. The program invested Medicaid dollars into food, housing, and transportation support for high-risk members, and within months, participants showed improved health outcomes and an estimated $1,020 annual reduction in healthcare costs per person. Yet despite these gains, the program was defunded this year. Why? Because the fiscal returns didn’t appear fast enough. Lawmakers looked for savings within one or two budget cycles — not over the five to ten years where prevention yields its true ROI. This is the challenge: building a healthcare system that values long-term cost avoidance as much as short-term budget balance. Preventive and social programs rarely fit the current accounting frameworks, but they are essential if we want to bend the cost curve sustainably. A shift toward “pre-care” investment, funding programs that reduce dependency before it begins. will require new models of evaluation, longer-term ROI horizons, and collaboration across agencies. The Healthy Opportunities Pilot proved the concept works. The question is whether our policymaking mindset is ready to support it. https://lnkd.in/eB5zPfMQ

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Round and round we go. Now BCBS MA is joining Aetna and Cigna in flagging, downcoding, or otherwise reducing payments for what they characterize as outlier claims and overbilling. The company estimates that only 1-2% of primary care physicians and 3-4% specialists will be affected. Docs are, understandably, upset. Reimbursement continues to decline. Costs continue to go up. The rules continue to change — CMS reformed E&M coding a few years ago to make documentation more clinically meaningful. Some argue the changes made it easier to satisfy higher complexity billing requirements (a 2025 Trilliant study confirms this trend). EMRs, for all their ills, lowered the "document-to-bill" barrier. Now artificial intelligence is poised to supercharge RCM. In a world where tech is expensive and startups need to justify big valuations, improved revenue capture through upcoding is the clearest path to ROI. Serve and volley. Punch and counterpunch. You take my knight; I take your bishop. On and on it goes. Considered on their own, these payer moves probably aren't as impactful or far reaching as the headlines suggest. Truth be told, there are clinicians who play the coding game very well...maybe too well. As the payers claim, they're likely a small minority. Some will change their behavior. Others will successfully appeal. Most docs will be unaffected. Viewed more broadly, is just another small move in the absurdist's never ending healthcare chess match. We'll see an avalanche of tech, the battle of the AI bots, until another stalemate is reached and it's on to the next gambit. The most salient point I heard at HLTH: if we spent more time building a better system, the showroom floor would be empty.

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