Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Costs

Data from Health Plans, PBMs Helps Lower Prescription Drug Costs

November 16, 2018 - The health information network Surescripts is using data from both payers and PBMs to give prescribers access to patient-specific and formulary-based benefit and cost information for nearly three-quarters of all covered lives in the country. At the point of care, there have been 30 million views of this data which is integrated within electronic health record technology via the...


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CMS Demonstrations Target Mental Health Services Under Medicaid

by Chuck Green

Medicaid beneficiaries with serious mental illness (SMI) or serious emotional disturbance (SED) are the targets of recent CMS efforts to improve health outcomes. In a letter to Medicaid directors across the country, the federal agency...

Addressing Healthcare Literacy Key to Health Plans Reducing Costs

by Chuck Green

The inability of consumers to successfully navigate the healthcare system, which costs employers and health plans billions in administrative costs. In a recent article in the Harvard Business Review, members of Accenture’s...

Venture-Funded Medicare Advantage Plans Launch into 2019 Market

by Thomas Beaton

Several Medicare Advantage (MA) plans entering the market for the 2019 plan year are backed by millions in venture capital funding and are planning to compete with established payers by promoting new health plan solutions. The recent...

Employer Wellness Programs Reduce Costs by Targeting Chronic Diseases

by Thomas Beaton

In order to reduce overall spending, employers should focus on designing wellness programs that target chronic diseases and address other clinical factors impacting employee health, says a new research paper from Transamerica. The...

Physical Therapy, Chiropractic Back Care Cut Opioid Use, Costs

by Thomas Beaton

Payers could improve outcomes, increase cost-effectiveness, and reduce opioid use for lower back pain by expanding non-pharmacological coverage such as physical therapy and chiropractic care, according to a new study published in JAMA...

Insured Critical Illness Beneficiaries Face High Treatment Costs

by Thomas Beaton

Health plan members with critical illnesses face high treatment costs and other financial issues even with comprehensive health insurance, said a new survey conducted by the Harvard T. Chan School of Public Health, New York Times, and...

Administrative Plan Costs for Managed Care Payers Jumped 5.7% in 2017

by Thomas Beaton

Managed care payers experienced a 5.7 percent increase in administrative plan costs in 2017, for items such as staffing and customer service support, according to an analysis from the Sherlock Company. Spikes in Medicaid enrollment...

BCBS of TN Defrauded $2M in $2B Telemedicine Insurance Scheme

by Thomas Beaton

BlueCross BlueShield (BCBS) of Tennessee has been named a damaged party after it was defrauded $2 million as part of a larger $2 billion telemedicine insurance scheme, according to the Department of Justice (DOJ). The District Court for...

Spending, Prescription Histories Identify Future High Cost Members

by Thomas Beaton

An individual’s healthcare spending and prescription drug histories are among the most accurate predictors of future high costs, according to a new Society of Actuaries (SOA) report. SOA used claims data collected by the Health Care...

Private Insurance Spending Has Outpaced Public Spending Since 2016

by Thomas Beaton

Private insurance spending has grown faster than Medicare and Medicaid spending since 2016, even though national enrollment has plateaued, says a new report from Altarum. The report suggests that higher per-enrollee spending, plus...

How Payers Can Develop a Medication Therapy Management Program

by Thomas Beaton

As the cost of medication non-adherence reaches over $300 billion annually, payers are increasingly challenged to provide new solutions to address the healthcare and economic impacts of non-adherence. Payers could develop a medication...

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...

Medicare Advantage Premiums to Decrease by 6% in 2019

by Thomas Beaton

CMS officially announced a six-percent decrease in Medicare Advantage premiums in 2019 as the result of MA enrollment, health plan options, and benefits increase. All signs point to the MA marketplace continuing to be a lucrative...

NYCHH Triples Denials Recovery from UnitedHealthcare to $40.1M

by Thomas Beaton

NYC Health + Hospitals (NYCHH) has more than tripled the amount the health system is seeking in claims recovery from UnitedHealthcare, from $11.1 million to $40.1 million after a comprehensive case-by-case review of high-profile...

Employers are Experimenting with Innovative Health Plan Designs

by Thomas Beaton

Just under half of employers participating in a survey from the National Business Group on Health (NBGH) are actively experimenting with innovative health plan designs that aim to foster new approaches to care delivery. NBGH found that...

31% of Beneficiaries Face Social Isolation, More Health Risks

by Thomas Beaton

A new survey of Humana’s commercial population has found that almost one-third of members over 65 years old experience social isolation. The survey reveals that payers could benefit by addressing social isolation among their elderly...

Montana Reinsurance Program May Cut Premiums Up to 20%

by Thomas Beaton

Montana is moving ahead with the idea of creating a reinsurance program for the state’s health insurance market.  The program may reduce premiums between 10 and 20 percent, said Governor Steve Bullock and Department of...

Risk Scoring, New Payment Models Can Reduce Medication Non-Adherence

by Thomas Beaton

Adopting new payment models, engaging in targeted risk scoring, and improving prior authorization processes may help payers address medication-non adherence among members with mental health concerns, says a report from the National Council...

Senators Propose Limits on Surprise Healthcare Billing

by Thomas Beaton

A bipartisan group of Senators has introduced legislation that aims to end surprise healthcare billing, a practice which can lead to extremely high out-of-pocket costs for consumers. The Protecting Patients from Surprise Medical Bills Act...

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