Joy Gilbert

GoodRx shouldn't exist And in fact, you don't need it Here's how it works: GoodRx aggregates PBM rates Customers filling prescriptions use GoodRx discount cards to access "better" "cash" rates at the pharmacy Pharmacies pay for the privilege of making less money by cutting in the PBM and GoodRx Nothing prevents the pharmacy from charging these prices for cash Oh, well, except for predatory contracting by the PBMs, gag-clauses, and all that horrible fun It's just demand aggregation arbitrage And maybe, just maybe the market knows it... GoodRx FY 2023: $750M revenue ($27M) ops loss ($8.9M) income loss But as always it's about the cash too $138M cash from operations But despite the cash generation, look at share price: $8.63 per share today $56.63 per share Feb. 2021 Now, there is a lot to unpack Including a hefty software capitalization of $60M and increased amortization of $50M and some restructuring to the tune of another $75M But if you love the color rose: $217M Adjusted (made up) EBITDA Nonetheless, GoodRx, a discount card rate aggregator has made $750M off a dysfunctional system It's not been great for shareholders And It's not great for the healthcare system If you want to see why this sausage gets made, tune in the Sunday to The Healthcare Breakdown We're talking about PBMs I know, it's gonna get wild Check it out here: https://lnkd.in/gVRtQGZN See you out there!

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This is quite incredible to see. Very few #CMMI demonstrations can point to any savings at all. And “…MSSP savings go further than savings generated by Medicare Advantage…” #ACO #VBP #Primarycare #MSSP #healthcareinnovation

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GASTROENTEROLOGY QUARTERLY UPDATES - 3rd Quarter - Live Webinar - July 10, 2024 - 1 hr web - 10am PT - 1 ceu from AAPC. SPECIAL DISCOUNT ADDITIONAL ATTENDEES - sign up first person at regular price - each add'l attendee(s) goes for $99 a person (includes their own connection, materials & ceu's) - limited spaces available at this rate, so signed up soon! Here's link to download registration and fax to (415)892-1271 or register online at McVey Seminars website - https://lnkd.in/g4SAuyic WANT AN AMAZING DISCOUNT? (for a short time this below discount has an extra $50 off for this week only - so take advantage of double savings for a limited time) TO GET THE NEXT 4 GI QUARTERLIES AT THE LOW PRICE OF $735.00 (BRINGS THE COST FROM $230.00 EACH TO $183.75> here's link to do all 4 sessions for 2024/2025 - https://lnkd.in/gNXFUe8 / #gastroenterology #gastroenterologist #gastrointestinal #gastro #gidoc #healthcare #medicalbilling #medicalcoding #medicalbillingandcoding #coding #billing

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I'm thrilled that today, we announced a significant milestone for Clover Health: the launch of Counterpart Health. Our innovative Clover Assistant (CA) platform is now available to all Medicare Advantage payors and providers under the new brand name Counterpart Assistant. Why am I so excited about this? This move is a strategic leap forward in our mission to improve healthcare for everyone. With Counterpart Assistant, we're not just expanding our reach—we're leveraging cutting-edge AI and machine learning capabilities that have already proven to make a real difference in patient care. The healthcare landscape is evolving rapidly, and the need for advanced, data-driven tools has never been greater. Medicare Advantage plans, in particular, are under pressure to improve patient outcomes while managing costs. That’s where Counterpart Assistant comes in. By bringing our technology to more providers, we're empowering clinicians with the tools they need to deliver high-quality, personalized care. What makes Counterpart Assistant special? First, we’re broadening our impact by allowing providers outside of Clover Health's Medicare Advantage plan to benefit from our technology. Our hybrid SaaS and shared-savings model aligns financial incentives with health outcomes, ensuring flexibility and scalability. CA’s AI-driven insights enhance clinical decision-making, and are associated with earlier diagnosis and better management of chronic diseases. Plus, we've built a robust support system to ensure seamless integration and ongoing assistance for all users. Clinicians using CA have seen significant improvements in Medical Cost Ratios and patient outcomes. The timing couldn't be better. The healthcare industry is ripe for transformation, and our technology is poised to lead the way. By expanding the use of Counterpart Assistant, we’re not just keeping up with the changes—we’re driving them. Join us on this exciting journey. Visit our website for more details. Thank you for your continued support as we strive to bring high-quality healthcare to everyone on Medicare. #HealthcareInnovation #AI #MedicareAdvantage #ValueBasedCare #CloverHealth

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💹 Tuesday morning, CVS reported its Q1 earnings, and the stock has dropped 18% as Wall Street did not like them leaning into Medicare Advantage at a time when it is riddled with challenges. Check out my substack but below are some of the takeaways. 👬 Similar to the Humana call, they documented many of the headwinds as they look to try to build their integrated network with CVS, Aetna, Caremark, Oak Street and Signify. Despite a revenue growth of $3 billion, reaching over $88 billion, net income took a significant hit, halving from $2.14 billion to $1.11 billion. Click on my substack for the full takeaways from the call with the highlights below: 📈 Key Highlights: ➡ Membership growth to 26.8 million, driven by 800k new MAPD enrollees (lost 300K Medicaid Members YOY) ➡ Revenue from premiums increased by 25%, despite the financial setbacks driven mainly by the 800K new Medicare members they fished out of the open enrollment period. ➡ They had a 580 basis point increase in the Medical Benefit Ratio (90.4%) from the elevated utilization in the Medicare population. The strategic acquisitions like Signify and Oak Street to bolster Medicare offerings are so early days and were not able to offset the headwind ➡ Similar to Humana and UNH, they are going to exit some geographies that are not as profitable along with price for a smaller range of services for 2025 Medicare bids. 🚀 Looking Ahead: - CVS plans operational adjustments aiming for a 4%-5% margin in the MAPD sector, despite expecting to operate at a loss in 2024 of 3%-4%. The longer term goal here will not be achieved in 2025 but is set for 2026 and beyond similar to other MAPD providers. - They are enhancing their pricing strategy for higher utilization in 2025 (probably not a great open enrollment coming for Aetna) and they have their fingers crossed for improving STAR ratings to potentially add $700 million in revenue next year. This was not a great call for CVS, as many expected some of their 2023 acquisitions to begin to bear fruit but in hindsight they bought a meme coin or stock (Medicare Advantage) at the peak as many of the MAPD challenges are major headwinds. I look for them to survive and advance in 2024 with the longer term goal of executing on their strategy. As always, feel free to reach out with your comments and input along with subscribing to my substack. #healthcare #marketaccess #earnings https://lnkd.in/gsf26HaJ

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We're making steady progress on the new 7/1 hospital pricing transparency requirements. Almost 40% of US hospitals have already released files that meet the more robust requirements. Idaho is in the lead as the most compliant state! Texas is beating out California. And the West Coast is still the best coast. There are two ways to look at this: A) The "Doctor Kelso" from Scrubs view: Only 40%?! Only 25% meet all the requirements?! Everyone is evil! B) The "Momentum is better than perfection" view: Healthcare can take years to shift, yet in 25 days, we've seen a relentless march of transparency going from acceptance to the new normal. Stories need villains. Solutions need data. I love that all sides are referencing the chart below in this critical debate over transparency data's effectiveness. Just remember, in 2020, few expected these regulations to go far. And now it's a mappable trend. One spark can go a long way. Don't stump it out because it's not a perfect story.

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🥊 A Tough Quarter for CVS – What's Next? 🚨 💊 CVS was the final "Big Six Payor" to reports earnings last Wednesday and I was able to dive into CVS's latest earnings report, and it's clear that the healthcare giant is facing some significant challenges. From Medicare Advantage headwinds to Medicaid acuity issues, CVS is navigating a complex landscape that’s testing Karen Lynch as she has moved to actively manage Aetna. 🗞 In this article, I break down: - The driving forces behind CVS’s Q2 performance and loss of free cash flow along with expanding expenses - Insights into their Medicare Advantage and Medicaid strategies headed into 2025 - The impact of the retail pharmacy contraction and biosimilar partnerships for Cordavis as they look to control the potentially 100 billion dollar market against Cigna and UNH If you’re following the healthcare industry, especially the dynamics among the “Big Six Payors,” subscribe below. CVS Reports Q2 Earnings jeffdelverne.substack.com I'd love to hear your thoughts on CVS’s current trajectory. Do you think they can successfully integrate Aetna, Signify, Oak Street, and Cordavis to turn things around? #healthcare #pharmacy

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𝐋𝐨𝐨𝐤𝐢𝐧𝐠 𝐟𝐨𝐫 𝐏𝐁𝐌 𝐒𝐨𝐟𝐭𝐰𝐚𝐫𝐞? I’ve been reaching out to PBM software companies to learn about their products and what sets them apart. Having worked with five different PBM platforms in the past, I’m very familiar with how these systems operate. If you’re in the market for PBM software, feel free to reach out—I’m happy to share what I’ve learned, free of charge. As a consultant, I focus on building strong relationships in the industry. I believe in the value of helping others because it leads to future opportunities. Whether you’re a small pharmacy, PBM startup, broker, TPA, hospital, or even a large PBM, let's connect. I’ll provide insights on the top players in the space and what differentiates them. If you’re with a PBM software company and we haven’t connected yet, send me a message, and let’s get in touch!

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What a deal! $29 to message your provider!? $49 for a virtual visit!? Well, I guess it's a deal compared to traditional health systems which charge.... $39+ per message $75+ per telehealth visit Or, you can get UNLIMITED virtual (text messages, email, video) visits with a DEDICATED care provider through HealthBar for $16/mo. Dedicated means it's the same person (think clinician in your family feel) nearly every time and it's someone how UNDERSTANDS you and will actually LISTEN! Or, you could just keep letting your workforce use healthcare haphazardly like this and hope your costs go down... probably not going to happen :) #healthcare #business #hr #insurance #benefits #ceo #cfo #virtualhealth

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If you’re waiting to renegotiate your payer contracts, you’re just making their shareholders richer 💸💼. I’m tired of hearing about healthcare providers getting shortchanged and not taking immediate action to increase reimbursements with payers. If you’re missing the data 📊, the strategy 🎯, the team 💪, or the negotiation skills 🤝—it’s time to level up. Don’t wait for a handout—it’s not coming. That 8% ‘increase’ they’re promising with the new contract? Likely smoke and mirrors. Model it out 📈, and you might find it’s actually a cut. Real case scenario and then we turned it around, from -1% to an 8%+. Gotta put in the work with the right tools!! Don’t trust that the payers are just doing you a solid. Never going to happen. That’s why you need a team of experts. The attached screenshot is a glimpse of this weeks negotiation wins at Aroris. At Aroris Health, we’re relentless in securing higher reimbursements that match your true value. It’s time to get paid what you deserve. Don’t leave money on the table—negotiate better contracts now! #Healthcare #PayerNegotiation #RevenueGrowth #HealthcareFinance #ArorisHealth Some of the biggest champions I know around preserving the spirit of medicine and getting practices paid with their worth: Brett Spark Mark Schroeder Chad Smoak Brett Buckingham Lindsey Perrin Brian W Hall Chad Herzog Bret Oettmeier Peter Nystrom Andrew Royer, OD David Russo, DO, MPH John Hutchinson Andrew Lundquist Stratum Med, Inc Stefano M. Sinicropi, MD Rachel Uzlik Troy Simonson Basir Tareen David Bittner Thomas Eicke, MBA, MS, RN James Hereford Chris Schultz Amy Jongerius Aria Sameni Michael R Redler, MD Jason Lennox

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Weekly lessons learned - Where did that $200 Billion of acute care revenue go? Hospital C-suites, Carter Williams and I did quick math >$200 BILLION in acute I/P revenue will evaporate if just 25% of those w/1 chronic condition take a GLP-1 and 50% of those avoid 1 hospitalization. This aligns w/Yubin Park, PhD recent data on ACR which would only add to this estimate. And hims & hers is showing this revenue shift real time with a 70% YOY increase Matthew Holt. Even 23andMe is making a comeback play w/Lemonaid Health (part of 23andMe) Sergei Polevikov, ABD, MBA, MS, MA 🇮🇱🇺🇦 Sticking w/"meanwhile an entirely new healthcare ecosystem is being built and we are still focused on heads in beds" 🙄 Superpower and Max Marchione went live with their beta and a video that liteally compares him to Steve Jobs, Bill Gates, Elon Musk and Jeff Bezos in 0:38 sec., well alrighty then. As of now it's a marketplace w/diagnostic testing akin to Function Health (on steroids) comingsoon. Josh Erndt-Marino 😉 One of my favorites Michael Muntner at Crestview Partners announced Cardinal Health has added a GI MSO and Advanced Diabetes Supply to its portfolio 😉 Thatch Chris Ellis is partnering with Quickbooks (hello 1 million small businesses) to bring ICHRA to the masses, hope POTUS doesn't kill it - Brad O’Neill Brendan Keeler was on fire pointing out that AI is actually live on Epic, TEFCA vetting process update and a substack piece for the ages chronically Epic's battle scars and brokedown AI w/impacts, Patrick McGill, MD MBA calls copilots a game changer and Christina Farr added to this by asking - Is AI "time savings" going to mean doctors and care teams get more time with their existing patients than the 6m visit? or have to do more... When will we learn our bricks and mortar lesson?! Forward Health literally imploded in a matter of months after burning $100M largely on pods Guy Culpepper, MD In food news 🥕 Dear health systems you have better choices than Sodexo! Matriark Foods (Anna Hammond) is now a Vizient, Inc #environmentallypreferredsupplier - you can impact your Scope 3 emissions goals AND provide healthy delicious foods to patients 🥑 If you don't know Clancy Harrison and The Food Dignity Movement you should If Robert F. Kennedy can steer clear of reversing vaccines, maybe he really can help "Making America Healthy" - #foodishealth vs. #pharmaisking. Graham Walker, MD Andy Mychkovsky Erin W. Martin Billy Wynne did a great piece in Health Affairs about what the election could mean for HC and Andrew Schwab continues to share great post election intel and Sachin H. Jain, MD, MBA weighed in on MA impacts For my next rabbit hole this week - the report for Accountable Health Communities Model is out Darshak Sanghavi along w/2023 ACO REACH 2023 results next week. $1.6B program savings results which Chris Deacon pointed out could in fact be losses via evaluation findings - I'm conflicted - after working with so many ACOs I know they create true value.

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The healthcare industry faces challenges in payment collection due to a technology gap between payers and providers. This disconnect leads to high rates of litigation, claim appeals, and underpriced claims. At REVELOHEALTH, we address this issue by aligning provider contracts with payer pricing technology to ensure contract integrity. Our CALIBRATE™ solution recently improved inpatient claim payments, reducing the need for appeals and uncovering significant underpriced claims, with Medicare Advantage claims being a notable area of focus. #healthcare #paymentcollection #technologyintegration Here are some consistent facts from a recent integration. (1.) Over 17.5% of inpatient claims are priced within 95% of the contracted rate. Less than 62.2% are paid within 1% of the contracted rate. Imagine if we had 95% of claims were priced within 1% of the contracted rate? (2) A single payer accounted for over $3.2MM of underpriced claims with an average of over $1,500 per claim. A provider will have to incur the additional claim appeal cost to collect this owed amount. (3) Medicare Advantage plans account for over 72% of the underpriced claims. (4) Simple E&M office visit codes are the primary source of underpriced physician claims. There is a better way than continuing to take the same historical actions. By using the same payer technology, a provider can determine the allowable for each episode of care immediately before incurring the high cost of traditional revenue cycle management. Is it about time we change our thinking about the cost of collection for healthcare payments?

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More than 300 independent pharmacies closed in 2023, creating pharmacy deserts in rural communities. PBMs have become key pieces of mega-health care companies that control the market from top to bottom. The three largest PBMs are each connected to a major health insurer. CVS Caremark owns Aetna and is number 6 on the Fortune 500 list. In 2023, CVS Health expanded into yet another health care space, creating a subsidiary that manufactures drugs. The 2nd largest PBM, Express Scripts, is owned by Cigna Group (number 16 on the Fortune 500). The 3rd, OptumRx, is owned by UnitedHealth Group, which is number four on the Fortune 500 list, and is the nation’s largest private health insurer and the largest employer of physicians. Per Becker's.....On Aug. 28, Rep. James Comer, chair of the House Committee on Oversight and Accountability, called on three PBM executives "to correct the record" regarding testimonies they made during a hearing about how the PBM industry influences prescription drug markets. "At our hearing, the witnesses claimed they do not steer patients to PBM-owned pharmacies," the committee wrote on X. "The executives also made claims contradicting the committee's and FTC's findings regarding contract negotiations, contract opt outs, and payments to pharmacies." Mr. Comer is asking David Joyner, president of CVS Caremark; Adam Kautzner, PharmD, president of Cigna's Express Scripts; and Patrick Conway, MD, CEO of UnitedHealth's OptumRx, to provide any necessary corrections to the record by Sept. 11. In his letter to the three executives, Mr. Comer highlighted the potential consequences of making false statements to Congress, including fines and imprisonment of up to five years. #pbms #fraud #spreadpricing #drugs #prescriptiondrugs #prescriptions #employers #middlemen #brokers #advisors #consultants #erisa #patients #employees #selffunding #carriers #medications #pharmacies #pharmacist

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Ethics and Honesty Matters CDI Director: Yes, I would like to see a demo of your CDI software, we are in the market for a new system to help with quality reporting. Our facility is not scoring well on quality measures and quality reporting. That is one of my priorities. CDI/HIM Salesperson: Sure, we can schedule, when will be a good time to schedule a demo, you will just love the functionality of the software solution, especially the ability to capture additional diagnoses that impact reimbursement and quality measures, driving quality scores Fast Forward- Hospital signs contract to license the software- after six months of use CDI Director: Mr. Salesperson, we are still having challenges ensuring the capture of diagnoses, our quality department is pointing out areas where the software could help our CDI staff be proactive in capturing all diagnoses and measures to ensure the record reflects the quality care we are providing. Salesperson: Yes, you did not purchase the module that will help your staff be proactive in alerting of diagnoses and exclusion criteria that will help in quality measure reporting. Just sign here and we can get that module up and running, it only costs an additional one million dollars. Your quality department will definitely want to see the hospital using this module. When honesty, ethics, and integrity matter, treat your potential customers respectfully, doing right for the client, and helping them meet their expressed needs. Client needs first, commissions second. #CDI, #qualitymeasures, #honesty, #integrity

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If you are an Employer who: 1) Covers GLP-1's and needs a partner to apply clinical/cost guardrails to reign in unnecessary spend. 2) Is contemplating covering GLP-1's and needs a trusted partner to navigate this dynamic category. 3) Needs to address medical costs by preventing downstream spend (ie. MSK, Type 2- Diabetes) through cardiometabolic health. 4). Understands that Obesity is a chronic condition and needs to be treated as such; through personalized, clinical patient care plans. . 5) Believe that medication without skill-building and lifestyle support is not a sustainable solution to longitudinal health.... ....You should consider us here at Wondr Health.

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Complete and utter nonsense from 340B Health in a pay-for-play The Wall Street Journal article. 👇 Re:"siphoned billions" From 2020 to 2023, total #340B purchases grew by $28 billion (+75%). The gross-to-net difference (list prices vs. discounted 340B purchases) also grew, by $15 billion (+35%). Article also includes brief anecdotes of larger health systems providing various community benefits--which they are required to do in order to enjoy tax-exempt status, regardless of 340B funds. smh ==> https://drugch.nl/4fBikKD

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What you won’t find: Wheel powering any of the sketchy DTC GLP-1 compounding companies. What you will find: This market exists because companies like Wheel, who prioritize clinical quality and regulatory compliance in every process and product, refuse to take shortcuts. We're committed to ensuring that patients receive high-quality care—not just drive quick profits. Sometimes, choosing ethics over revenue means we don't see a short-term windfall during a "Gold Rush." But as CEO, I can assure you that it also means that patients, customers, and clinicians can trust that Wheel is always on the right side of history. I believe GLP-1s will transform healthcare as profoundly as AI, and Wheel is dedicated to being at the forefront—delivering compliant, accessible, and responsible care.

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