Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

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Pros and Cons of High Cost Sharing for Employer Health Plans

May 23, 2018 - Employer-sponsored health plans that include high cost sharing expectations can help control spending for plan sponsors, but could create longer-term health risks for employee beneficiaries.   Striking the right balance between lowering costs and enabling healthy decision-making can be a challenge for employers and payers looking to design cost-effective plans.   How can plan sponsors...


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How Payers Identify, Succeed in Health Plan Market Opportunities

by Thomas Beaton

Healthcare payers that wish to be known as innovators need to continually be on the lookout for emerging health plan market opportunities that offer strong profit potential. Payers need to monitor specific market indicators and implement new...

Assessing Providers for Participation in Value-Based Care Contracts

by Thomas Beaton

Creating strong networks of high-quality healthcare providers can be a major challenge for any payer looking to expand its value-based care contract portfolio. Providers aren’t the only ones accepting risk when entering into pay-for-performance...

Adding Telehealth, Remote Care Benefits into Health Plan Options

by Thomas Beaton

Payers that include telehealth and remote care benefits in their health plan options could position themselves as leaders in health plan value, convenience, and innovation. Health plans are challenged to improve customer service and member satisfaction...

Improving Health Plan Customer Service Through Technology

by Thomas Beaton

High quality health plan customer service is critical for payers who want to create meaningful, positive beneficiary interactions. Customer service plays several important roles for health plans.  In addition to the stand-alone goal of leaving...

How Payers Can Address Food Insecurity among Plan Beneficiaries

by Thomas Beaton

Payers are constantly challenged to provide their health plan beneficiaries the best possible healthcare experiences, but may have trouble doing that if members experience food insecurity. Food security is just one lifestyle need that plays into...

Medicare Advantage Data Transparency Can Enhance Insights

by Thomas Beaton

Expanding Medicare Advantage data transparency may allow researchers to gain more comprehensive insights into cost and quality within the popular MA program. Healthcare experts and academic organizations currently have limited Medicare Advantage...

How Payers Can Add More Value to Medicare Advantage Health Plans

by Thomas Beaton

Payers striving to compete in the Medicare Advantage (MA) market can add more value to their health plans by taking advantage of regulatory changes established under a new final rule. Starting in plan year 2019, payers can offer a greater variety...

Top 10 Highest Performing Medicare, Medicaid Health Plans

by Thomas Beaton

The top-performing Medicare and Medicaid health plans for the 2017-18 plan year earned exceptional quality scores based on the plans’ customer satisfaction, preventive care, and treatment outcomes of beneficiaries, according to the most...

Top 10 Highest Performing Commercial Health Plans

by Thomas Beaton

The top performing commercial health plans in the US for 2017-18 exceeded expectations for customer satisfaction, preventive care, and outcomes of their beneficiaries, according to the National Committee for Quality Assurance (NCQA). NCQA aggregated...

How Payers Can Build a Successful Bundled Payment Strategy

by Thomas Beaton

Bundled payment models are a popular reimbursement option for payers because they present an opportunity to improve healthcare quality, lower costs, and participate in value-based agreements with limited financial risk.   However, if payers...

Affordable Care Act Changes May Bring a Rocky 2018 for Payers

by Thomas Beaton

2017 was a turbulent year for the Affordable Care Act.  Legislative battles in Congress, fluctuating support from healthcare stakeholders, and threats of repeal have left many payers facing an uncertain future. Even though Congress has not...

All-Payer Claims Databases Offer Insights into Healthcare Spending

by Thomas Beaton

All-payer claims databases (APCDs) allow payers, providers, and regulators to analyze claims from millions of beneficiaries to learn where spending is directed and whether or not spending on certain healthcare services is avoidable. State-level...

How Payers Can Streamline Prior Authorization for Prescriptions

by Thomas Beaton

Prior authorization may allow payers to limit unnecessary spending on high-cost prescription drugs, but leading provider experts suggest that payers could do more to boost the efficiency of prior authorization procedures for clinically valid...

How Process, Outcome Measures Contribute to Population Health

by Thomas Beaton

Payers rely on process and outcome quality measures to communicate healthcare performance to new and current beneficiaries. Quality measurements such as HEDIS, CMS Star Ratings, and standardized core quality measures (CQMs) are some of the tools...

How HEDIS, CMS Star Ratings, CQMs Impact Healthcare Payers

by Thomas Beaton

Quality performance metrics such as HEDIS, CMS Star Ratings, and standardized core quality measures (CQMs) can give consumers an objective indication of healthcare payer quality. Standardized quality measures aggregate how well a payer has performed...

Why Bundled Payments Are a Popular Option for Healthcare Payers

by Thomas Beaton

Bundled payments are ideal for payers that want to participate in value-based care. Bundled payments tend to have lower financial risks than other payment models for payers and are beneficial to providers as well as payers. In a bundled payment...

Member Engagement, Payer Spending Lead Top 10 Stories of 2017

by Thomas Beaton

The 2017 news cycle was a constant flurry of political and financial developments for payers. From the turbulent efforts to repeal and replace the ACA in the House and Senate to challenges with member engagement, population health, and cost cutting,...

How Provider-Sponsored Health Plans Can Find Consumer Success

by Thomas Beaton

Provider-sponsored health plans (PSHPs) are seen as a way for provider organizations to compete with commercial payers while lowering their own costs and improving care quality, because provider organizations can manage the cost of healthcare...

The Pros and Cons of Pharmacy Benefits Managers for Payers

by Thomas Beaton

Prescription drug spending is a billion-dollar problem for the payer industry. While pharmacy benefit managers (PBMs) are often a positive way for payers to manage prescription drug benefits for their members, savings for payers can be limited...

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