Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Payer Interviews

Cigna’s Digital Diabetes Prevention Program Cuts Costs, Ups Outcomes

by Thomas Beaton

With more than one out of every three Americans living with prediabetes, payers are actively seeking out innovative strategies for preventing progression of the costly and life-changing disease.   Most payers offer clinical benefits to...The program also ties into Cigna’s financial goals around moving towards value-based care, she added. “We really like the DPP because we believe that we need to continue to move the market to value-based payment,” she said...

Earning Top Medicare Advantage Ratings Requires Data, Ambitious Goals

by Thomas Beaton

Succeeding in the highly competitive Medicare Advantage (MA) market requires more than just a sense that there are financial gains to be had in this growing health insurance segment. Payers that wish to reap some of the many financial rewar...“The MA entry was a health plan-wide initiation of a brand-new product line. And that's not something to undertake lightly,” Wright said. “We wanted to make sure that we could develop that, do it well, scale it, and gr...

How to Improve Cost Sharing to Enhance Chronic Disease Management

by Thomas Beaton

A tailored cost sharing program that helps beneficiaries pay for chronic disease care can reduce wasteful spending and increase access to chronic disease management services. However, relying on one-size-fits all cost-sharing plans can make...Unstructured, non-targeted cost sharing can create both spending and quality of care concerns. Fendrick explained that beneficiaries may end up experiencing financial burdens if they are paying significant sums for high-frequency services. ...

Using a Commercial Shared Savings Program to Reduce Care Costs

by Thomas Beaton

A commercial shared savings program equipped with the right leadership, clinical insights, and comprehensive care strategies can help payers save significantly on healthcare costs and produce exceptional beneficiary outcomes. In order to ac...“Any health plan that doesn't have a team of people dedicated to this effort for value-based care, or any plan that's not trying to engage the community of providers and partnerships in different ways, is probably going to fal...The creation of a shared savings program requires the use of performance measures in order to develop savings goals, says Wallace. In 2015, BCBSAZ and ACO Partner chose specific HEDIS measures to support quality improvement monitoring, incl...

How Payers Can Succeed Under Updated 2019 HEDIS Measures

by Thomas Beaton

The Healthcare Effectiveness Data and Information Set (HEDIS) provides 90 percent of America’s health plans with the ability to directly compare performance across the national stage.   Currently, the HEDIS set contains 92 measur...Some of the changes to some of the requirements around preventive care and chronic disease management for 2019 may require payers to work with their contracted providers to ensure delivery of care, while others will alter the way payers rep...

Helping Payers Implement Value-Based Hospital Reimbursement

by Thomas Beaton

Hospitals generate some of the largest revenues and create exceptionally high costs for payers, which combine open the possibility for value-based hospital reimbursement programs to control spending.        In March 2018...

Using Social Determinants of Health for Risk Stratification

by Thomas Beaton

Engaging in meaningful risk stratification of beneficiaries requires accurate data that can highlight opportunities to reduce costs and improve outcomes for plan members. In order for payers to develop accurate and detailed risk stratificat...Gateway Health serves around 600,000 Medicare and Medicaid managed care members across seven states, including Pennsylvania, Delaware, West Virginia, Ohio, Kentucky, Arkansas, and North Carolina. “In the managed care environment, we n...

How Payers Can Effectively Scale Value-Based Care Networks

by Thomas Beaton

Value-based care networks are a promising opportunity for payers that want to manage costs and improve outcomes of beneficiaries.  But effectively scaling collaborative, risk-based reimbursement networks for millions of beneficiaries r...In order to produce the most impactful results, BCBSA focused on trimming inefficiencies and closing care gaps around chronic diseases like diabetes and cardiovascular conditions. Hedges said that BCBSA saw the chronic disease outcomes of m...

How Payers Address Deep-Rooted Social Determinants of Health

by Thomas Beaton

The social determinants of health (SDOH) have gained traction in payer discussions and are driving payers to take a thoughtful look into factors that create long-lasting effects on healthcare costs and outcomes. Payers recently have impleme...Payers must be mindful of which social determinants are critical to address based on local factors. Graham learned through his work with the Aetna Foundation that national trends surrounding health equity sometimes don’t factor into a...

Bundled Payments Require Clinical Insights, Provider Buy-In

by Thomas Beaton

Payers see bundled payments as a way to promote value-based reimbursement practices but must first leverage clinical insights and provider buy-in to maximize a bundle’s potential effectiveness. Bundled payments are valuable to payers ...“And to the extent that providers can manage a member population effectively, and drive out unnecessary or duplicative care, they can benefit from that through our incentive programs,” he added. A bundled payment program needs t...

How Payers Can Succeed in Association Health Plan Markets

by Thomas Beaton

Association health plans (AHPs) may completely alter the nation’s health insurance markets with increasing support from federal entities and a handful of state insurance commissions. An expansion of the AHP market may materialize base...The longer-term effects of an AHP expansion would include the destabilization of individual and small group risk pools as mass-market migration grows from the regulated markets into the AHP market. “As an unlevel playing field starts ...

Member Engagement is Key for High-Deductible Health Plan Success

by Thomas Beaton

Payers and employers who offer high-deductible health plans (HDHPs) to attract low-cost members may need member engagement strategies to generate higher value for these beneficiaries. Member engagement is critical for HDHP success because l...“These changes, of course, were an attempt to manage this healthcare trend of overindulgence in healthcare utilization,” Oldman said. “For example, if a consumer is purchasing something, and they have no idea about costs o...

Patient, Provider Engagement Drives High Health Plan Performance

by Thomas Beaton

Health plan performance, and how to improve it, is always an issue at the forefront of payers’ minds.  While payers have engaged in several strategies in the past aimed at improving clinical quality, reducing costs, and boosting ...“It can be helpful if your provider is seeing these regular reports, or logging into a portal to view quality performance in a particular population compared to other providers.  No one wants to be at the bottom of the heap,&rdqu...“The health plan directly attributed rate improvements to the changes made in both pharmacy policies, in terms of what could be dispensed and when, and the education that they delivered and engaged providers,” she explained. Eng...

Member Incentives for Lower Cost Health Services Saved Payer $3.2M

by Thomas Beaton

Commercial payers struggling to curb costs and encourage their members to make smarter financial choices may be able to save millions of dollars each year by investing in modest member incentives. Offering small financial rewards for choosi...“In New Hampshire, currently we see a range of $2,500 to $7,000 on remicade infusions depending on where it’s done,” Weden said. “Is the transfusion done in an infusion center? Is it done through home infusion? Is it...

Payer, Provider Collaboration Required for Accountable Care Success

by Thomas Beaton

The accountable care organization (ACO) movement has gained traction over the last year as payers and providers begin to share the same viewpoints on the benefits of value-based care. Provider attitudes about ACOs and related value-based ca...

Employer Health Plans Can Engage Members with Data, Targeting

by Thomas Beaton

The use of data analytics and employee wellness engagement platforms may help employer health plans improve spending efficiency while producing a healthier, more productive workforce.    Employees are not always ready to take part...

Quality Measures Challenging in Pharmaceutical Value-Based Contracts

by Thomas Beaton

Healthcare payers may find it difficult to establish value-based contracts (VBCs) with pharmaceutical companies due to the challenges of creating meaningful, workable quality measures.   Pharmaceutical companies are generally reluctant...

Payers Driving Value by Promoting Connected Care Models

by Thomas Beaton

As payers vie to remain competitive in commercial insurance markets, they must be able to effectively manage consumer costs while providing beneficiaries the best possible healthcare experience now and in the future. Rising healthcare costs...Developing point-of-sale interfaces that allow new health plan consumers to navigate without a representative is key, as indicated by the rise of on-demand services accessible through personal devices. “Gen Z and the millennials are c...

Planning for Individual Insurance Exchange Stabilization in WA

by Thomas Beaton

State health insurance markets and their individual insurance exchanges have faced regular instability in the form of payer exits, imbalanced risk pools, and rising premiums that push out new and returning insurance consumers. As premiums g...

Medicaid Analytics Support Social Determinant Incentive Payments

by Thomas Beaton

Payers looking for innovative ways to control the costs of care have been turning their attention to the social determinants of health, the non-clinical factors that often lead to issues with care access, non-adherence, and the development ...“For some years I had been told by multiple payers that they strongly suspected that these factors were important, but they couldn’t just make up a number,” said Dr. Arlene Ash, a professor of quantitative health sciences ...

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