Health Care Matters | January 17, 2025
Health Systems, Hospitals, and Vendors Banking on AI to Improve Efficiency and Increase Savings
Health systems and post-acute care providers are increasingly leveraging artificial intelligence (AI) to address critical challenges and improve operational efficiency. Companies like Aidin, PointClickCare, and WellSky are integrating AI tools into their software platforms to streamline patient transfers and reduce hospital readmissions. These AI-driven solutions help hospitals quickly identify available post-acute care services, such as skilled nursing and home health, by matching patients with the most appropriate providers in real-time.
In a related development, Kaiser Permanente led a $275 million Series F funding round for Innovaccer, a health care technology company focused on unifying patient data across health systems and enhancing AI and cloud capabilities. Read more here and here.
Why It Matters
AI is rapidly transforming the health care industry, offering lofty promises to improve efficiency, patient outcomes, and reduce costs. AI’s ability to process and analyze vast amounts of data quickly and accurately can enhance clinical decision-making and enable more personalized treatment plans. Additionally, AI has the potential to streamline administrative tasks, reducing the burden on health care providers and allowing them to focus more on patient care. However, the widespread adoption of AI in health care is not without its challenges. Issues such as data quality, high implementation costs, regulatory barriers, bias, and privacy concerns remain significant obstacles.
To address these challenges, the U.S. Department of Health and Human Services (HHS) recently released a strategic plan that aims to guide the responsible use of AI in health care. The plan outlines four key goals: catalyzing innovation, promoting trustworthy AI, democratizing access to AI, and fostering an AI-empowered workforce. These efforts aim to create a framework for safe AI adoption in health care, driving innovation while addressing challenges. Together, these initiatives highlight the growing reliance on AI to enhance health care efficiency and generate savings across the industry.
Aetna Suit Against Private-Equity Radiologists Tests No Surprises Act
STAT+ and Modern Healthcare both reported that Aetna has filed a lawsuit against Radiology Partners, accusing the private equity-backed radiology group of exploiting the No Surprises Act to fraudulently inflate reimbursements. The lawsuit claims Radiology Partners manipulated the billing arbitration process set up by the act to secure higher payments by remaining outside of Aetna’s network. According to Aetna, Radiology Partners used its affiliate, Mori, Bean & Brooks (MBB), to falsely bill for services provided by other radiology groups, misrepresenting the service provider to boost reimbursements. The lawsuit raises concerns that the No Surprises Act may unintentionally encourage providers to sell to private equity firms, which have been successful in securing higher payments through independent arbitration. Read here and here.
Why It Matters
The Aetna vs. Radiology Partners lawsuit is significant because it challenges the effectiveness of the No Surprises Act, which was designed to protect patients from unexpected out-of-network bills and reduce financial incentives for providers to avoid insurer contracts. Aetna alleges that Radiology Partners, backed by private equity, manipulated the law's independent dispute resolution (IDR) process to inflate reimbursements by staying out of its network. If proven, this could expose the act’s potential to unintentionally enable some providers to exploit the system for higher payments, instead of fostering collaboration with insurers.
This case could set an important precedent for how the IDR process is interpreted and enforced, potentially leading to stricter regulations and oversight. If Aetna prevails, it may prompt changes to ensure the No Surprises Act fulfills its purpose of protecting patients and promoting fair billing practices.
Where We Are Going
Beyond the Headlines: GLP-1’s Role in Whole-Person Primary Care
The Primary Care Collaborative is hosting a webinar on January 29th at 1pm ET discussing how to best integrate GLP-1s into whole-person primary care and how these treatments can provide a foundation for a broader approach to managing chronic conditions. Register here.
What We Are Reading
Successor Models, Scaling Pathways, and the CMS Innovation Center
Senior leaders at the CMS Innovation Center published a blog describing the Center’s efforts to iteratively test concepts and build on lessons learned from an originator model to successor models. Read here.
3 Biden Health Care Regulations Trump Will Have to Finalize
The incoming Trump administration will need to address several key health care regulations left unfinished by President Joe Biden. These regulations include those related to Medicare Advantage, including the Medicare Advantage and Part D payment policies proposed last Friday, remote prescribing of controlled substances, and the No Surprises Act. As President-elect Donald Trump prepares to take office next Monday, his team will have to decide whether to retain, modify, or eliminate these proposed rules. While the Biden administration could potentially finalize some of these regulations in its final days, it is more likely that these decisions will fall to the new administration. Read here.
No Doc Fix or Advanced APM Bonus: What Happens Next?
This study explores whether hospital participation in the Acute Hospital Care at Home program continued to increase following the extension of theFor the second year in a row Congress failed to enact a doc fix or Advanced Alternative Payment Model (APM) bonus extension. While Congress did act last year on both counts through the 2024 Consolidated Appropriations Act (enacted March 2024), it remains to be seen whether Congress will do so again in 2025. To explore what this means for provider payments in 2025, read here.
VBC Resources
HCTTF Celebrating Ten Years in Value-Based Care: Reflections and Foresights
In October 2024, the Health Care Transformation Task Force turned 10 years old. In recognition of this anniversary, the Task Force released a two-part paper reflecting on the past 10 years of health care transformation and envisioning a path forward for the coming decade. View the resource here.