Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

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Why Bundled Payments Are a Popular Option for Healthcare Payers

December 11, 2017 - 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 arrangement, payers are only responsible for a single payment that covers all the services included in a defined episode of care, which means there...


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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...

How Payers Can Improve the Value of Small Business Health Plans

by Thomas Beaton

Payers offering insurance plans for the employer market need to provide flexible benefits and cost-saving strategies that create value for small businesses. Small businesses are an excellent market opportunity for payers because health plans...

Ensuring High Out-of-Pocket Spending Won’t Lead to Negative Outcomes

by Thomas Beaton

High deductible health plans (HDHPs) are intended to reduce payer and beneficiary spending on healthcare services, but untenable out-of-pocket spending for beneficiaries could lead to patients letting preventable conditions develop into catastrophic...

Top 5 Most Common Healthcare Provider Fraud Activities

by Thomas Beaton

Healthcare provider fraud is extraordinarily common and can be conducted at a shockingly large scale.  The largest healthcare provider fraud takedown in US history was announced just recently, resulting charges against 400 defendants in...

Payer Strategies for Improving Member Medication Adherence Rates

by Thomas Beaton

Payers are spending billions of dollars annually on medications that aren’t improving the health outcomes, with financial and health literacy proving to be the most common barriers to adherence. Avoidable healthcare spending totaling between...

Top 4 Consumer Wellness Benefits for Payers to Add to Health Plans

by Thomas Beaton

As payers explore innovative ways to improve beneficiary engagement and satisfaction, they may wish to consider adding enhanced consumer wellness benefits to their health plan offerings. Health plans that take a proactive approach to engaging...

Why the Generic Drug Market is a Growing Payer Opportunity

by Thomas Beaton

As payers try to ease the rising costs of prescription drugs, which account for 10 percent of national healthcare spending, they may wish to turn to the generic drug market to help curb unnecessary spending and improve profitability.   Generics...

How the Medicare Advantage Market Can Offer Payer Opportunities

by Thomas Beaton

Medicare Advantage (MA) market data from A.M Best and the Kaiser Family Foundation reveals that the MA market has remained profitable and provides financial opportunity, but payers looking to enter into the market should expect to address developing...

What are the Pros and Cons of Consumer Directed Health Plans?

by Thomas Beaton

In recent years, payers have been extending their consumer-directed health plan (CDHP) offerings as a way to encourage health plan enrollment and save on healthcare costs. Many healthcare stakeholders see CDHPs as products that create mutual...

Payer Strategies for Boosting Consumer Engagement, Satisfaction

by Thomas Beaton

In an increasingly competitive health insurance environment, payers that can successfully increase consumer engagement and beneficiary satisfaction will be best positioned for success. David Biel, the US Leader for Health Plans consulting at...

Top Commercial Payers Offering Medigap, MA, and Medicaid Plans

by Thomas Beaton

The top payers with the highest enrollment numbers for Medigap, Medicaid, and Medicare Advantage (MA) are a unique mix of some of the largest commercial payers as well as smaller to mid-size insurers, a new report from AHIP reveals. These three...

How to Create Balanced Risk Pools that Lower Premiums

by Thomas Beaton

Payers have been increasingly challenged to manage the high cost of healthcare while lowering the premiums their beneficiaries pay.  Creating balanced risk pools that benefit medically complex individuals while also serving healthier consumers...

Beneficiary Segmentation, Spending by Healthcare Payer Type

by Thomas Beaton

Healthcare spending in the US continues to grow steadily across all beneficiary segments and healthcare payers. 2015 data from CMS, the CDC, and the Kaiser Family Foundation (KFF) indicates that payers and individuals sponsoring their own healthcare...

Payer Pricing, Partnership Strategies for Population Health

by Thomas Beaton

Effective population health management and comprehensive preventive care open the door to new opportunities that maximize payer spending, raise care quality, and slow the progression of costly chronic conditions such as diabetes and cardiovascular...

Top 10 Healthcare Spending Categories in the United States

by Thomas Beaton

The upward trajectory of US healthcare spending doesn’t seem to be slowing down anytime soon, leaving payers, providers, and beneficiaries wondering how to control costs while maintaining a high level of quality. Value-based contracting...

How Pharmacy Benefit Managers Lower Prescription Drug Prices

by Thomas Beaton

Payers in both the private and public sectors require new strategies that offset the rising cost of prescription drugs. Pharmacy benefit managers (PBMs) are professionals that administer prescription drug plans for payers, employers, and CMS...

How Preventive Healthcare Services Reduce Spending for Payers

by Thomas Beaton

Reducing healthcare spending is a multi-faceted challenge for payers that requires creative and innovative strategies like offering a wide range of preventive healthcare services in health plans. Payers that encourage beneficiaries to take advantage...

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