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Managed Care

Jesse Ford
Having a payer collaboration leader is especially important for large health systems that have yet to fully consolidate revenue cycle operations following a merger or have far-flung operations in multiple states. They may vary in some details, but the same payer issues tend to crop up across a health system.
December 2018: Managed Care
Emad Rizk
The past decade has seen advances in payer-provider collaboration and data sharing that reflect clinical, economic, and administrative alignment. What's needed now is a deeper level of commitment to drive sustainable improvements in quality and cost.
December 2018: Managed Care
Richard G Stefanacci, Terri Schieder
Population health service organizations (PHSOs) are supplanting management service organizations that gained popularity in the '90s. PHSOs are emerging as the organizations within health systems that can improve the clinical and financial outcomes of the populations the health systems serve.
December 2018: Managed Care
Petra Esseling
Despite high need and urgency, patient adherence is low. One might think that puts the onus on patients, but a major reason for this gloomy picture is the severe shortage of mental health professionals across the country-a shortage that's only going to increase.
December 2018: Managed Care
Adam E Block
PURPOSE: Using New York City as an example, this research explores reasons for the consistently poor financial performance of three start-up health plans (Health Republic, CareConnect, and Oscar) while other health plans have performed relatively well in the same market. DESIGN AND METHODS: This study compiles insurer data from financial years 2014 through 2016, submitted to the New York State Department of Financial Services as part of the rate-review process, including premium revenue, claims cost, risk adjustment, administrative costs, net income, and premium...
December 2018: Managed Care
Peter Wehrwein
Blue Health Intelligence conducted an analysis of a commercial health plan claims database and adverse events that is designed to paint a fuller, real-world picture of adverse events. The database included patients, ages 18-64, admitted to the hospital in 2016 and 2017.
December 2018: Managed Care
Robert Calandra
Getting vertical theoretically will allow the new entities to capitalize on efficiencies in care management, total cost of claims, and other programs while creating an all-in-one health care product that provides more services at less cost. At least that's the spin.
December 2018: Managed Care
Thomas Reinke
The credibility of cannabis as a source of a legitimate pharmaceutical ingredient in prescription medications took a major step forward in 2018 when the FDA approved Epidiolex (cannabidiol) for two types of severe seizures. Epidiolex was a stellar candidate for approval. It reduced convulsive seizures by about 40% and has a good safety profile.
December 2018: Managed Care
Frank Diamond
Not that plans won't be taking a close look at some innovative approaches such as addiction recovery medical homes. One model includes bundled payments and performance bonuses, nationally recognized quality metrics, and the placement of treatment and recovery providers close to where patients with substance use disorder live.
December 2018: Managed Care
Jan Greene
We'll see what happens to the administration's Part B proposal. Congress is not likely to take bold action, partly because drugmakers are a strong influence on both parties. That leaves the FDA and Administrator Scott Gottlieb, MD, as major players in efforts to rein in drug prices.
December 2018: Managed Care
Richard Mark Kirkner
This fall, PricewaterhouseCoopers issued a report on blockchain in health care and outlined six areas where it could have a profound impact: supply chain and inventory management; enrollment and provider data management; back office functions and payments; data management; managing risk and regulatory issues; and research and development.
December 2018: Managed Care
Jan Greene
It's a tight labor market and employer surveys show a modest but steady uptick in employer health benefit spending for the coming year-about 5% on average. Much of that increase will go toward specialty drugs, the benefit with the biggest price hikes.
December 2018: Managed Care
Robert Calandra
The ACA-and more specifically, the individual ACA exchange market-is doing quite well these days, thank you very much. ACA premium prices have stabilized and even gone down for many plans. In October, CMS announced that the average premium for the second-lowest-cost silver plans for 2019 had decreased by 1.5%.
December 2018: Managed Care
Richard Mark Kirkner
Is it any wonder that Republican office holders are changing their tune regarding pre-existing conditions? Kaiser Family Foundation polling reports that overwhelming majorities say it is "very important" that the ACA's protections for people with pre-existing conditions (75%) remain. Even 58% of Republicans agree.
December 2018: Managed Care
Michael D Dalzell
CMS's Bundled Payments for Care Improvement (BPCI) Advanced program signals a willingness among Medicare providers to redesign care and take on risk. More than 1,500 hospitals and physician groups signed up-north of what was expected for a program that includes downside risk from Day 1. Commercial payers are watching closely.
December 2018: Managed Care
Timothy Kelley
In 2019, a record 36% of Medicare beneficiaries will be getting their benefits in a Medicare Advantage plan. CMS has broadened the services such plans can provide-services that may reduce expensive treatments and injuries. Insurers continue to see the market as a business opportunity. Critics see a slow-motion privatization of the entitlement.
December 2018: Managed Care
Ed Silverman
The PBM unit of the health giant CVS decided that any new drug exceeding $100,000 per quality-adjusted life year (QALY) may be excluded from the formularies that are maintained by its clients. Patient groups (with the backing of pharma) say that the measure is discriminatory.
December 2018: Managed Care
Robert Royce
Britain's National Health Service is taking a good look at how Americans do ACOs. But the move toward accountable care in England has already gotten mired in disputes (and confusion) about what organizational form it should take and whether current proposals are legal.
November 2018: Managed Care
Neil Minkoff
It may seem obvious, but people are more likely to remain engaged in an activity if they find it enjoyable-and outcomes back this up. Among the more than 1,000 patients who enrolled in our multiple sclerosis registry, 95% remained active after one year.
November 2018: Managed Care
Ellen Harrison
CMS continues to push on measuring and reporting information from the consumer perspective for Medicare Advantage and Part D contracts. Others will follow, and we can expect more emphasis on member-reported outcomes and experience measures across all lines of business.
November 2018: Managed Care
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