Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Payers

AHIP: Graham-Cassidy Bill a Poor Choice for Payers, Patients

September 22, 2017 - AHIP believes that passage of the Graham-Cassidy Bill making the rounds in the Senate would adversely affect payer market through policies that destabilize the health insurance markets, reduce patient access to healthcare, and fail to meet the criteria of a sustainable solution for the industry.   “Throughout this debate, we have been committed to engage in a collaborative, constructive...


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Anthem to Acquire FL Medicare Advantage Organization HealthSun

by Thomas Beaton

Anthem entered into an agreement to acquire Florida-based HealthSun, a payer and integrated health system that provides care and coverage to 40,000 Medicare Advantage beneficiaries, the payer announced in a press release.   Leaders at Anthem...

Pharmaceutical Industry Slow to Embrace Value-Based Contracts

by Thomas Beaton

Sixty-one percent of pharmaceutical companies are not yet participating in value-based contracts due largely to the belief that current policies make it too difficult to negotiate with payers and see a return on investment, according to a PricewaterhouseCoopers...

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...

More Payers, More Providers Increase Price Negotiation Power

by Thomas Beaton

Payers that operate within healthcare markets with a high concentration of payers and providers prices can negotiate the price of services up to 19 percent lower than those operating in low-concentration payer-provider markets, found a new study...

Pharmacy Benefit Manager Accountability is Key for Employers

by Thomas Beaton

As prescription drug costs continue to rise employers should ensure that they have strong pharmacy benefit manager (PBM) accountability measures in place to maximize cost-savings and plan efficiency, according to a report from the Midwest Business...

Cost of Implementing Quality Measures Key for Value-Based Care

by Thomas Beaton

Healthcare payers and providers must develop a better sense of the costs and burdens of implementing quality measures if they are to succeed with value-based care, according to the authors of a recent commentary in JAMA. Leaders from Boston Children’s...

MS Medicaid Recovers $8.6M in Fraud, Improper Payments

by Thomas Beaton

The Mississippi Division of Medicaid (DOM) recovered $8.6 million dollars from claims that were either directly fraudulent or improperly filed, the DOM announced in a press release. Through collaboration between Medicaid Fraud Control Units (MFCUs)...

Competitive Bidding Curbs Medicare Durable Medical Equipment Costs

by Thomas Beaton

A research team from the Health Care Cost Institute (HCCI) found that the Competitive Bidding Program (CBP) lowered Medicare costs on durable medical equipment (DME), bringing spending down to levels experienced by many commercial payers. The...

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...

ACA Risk Adjustment Leads Northwell to Shutter Insurance Plan

by Thomas Beaton

Northwell Health will end the sale of its CareConnect health plans in New York after hefty risk adjustment payments resulted in financial losses for the program, the health system announced. ACA risk adjustment payments totaling $112 million...

Pre-Authorizations, Rx Limits Cut Opioid Abuse by 30% Nationwide

by Thomas Beaton

Anthem BlueCross BlueShield (BCBS) organizations across the country collectively pledged to lower opioid abuse by 30 percent, and the company as a whole reached that goal two years ahead of schedule according to a press release. Declared a national...

Small Employer Health Plan Quality on Par with Larger Groups

by Thomas Beaton

Small employer health plans can deliver similar levels of quality with many of the same cost controls as larger employers, according to new research from United Benefits Advisors (UBA). A “less is more” approach can provide significant...

Employer Reference Pricing Lowers Prescription Drug Expenses

by Thomas Beaton

As payers and employers learn to counter significant increases of prescription drug expenses, reference pricing may hold the key to lowering drug spending and increasing consumer purchases of lower cost drugs, according to research published...

Medicaid Reform Requires Outcomes-Based Innovation, Better Data

by Thomas Beaton

Medicaid has steadily provided low-income patients with quality healthcare coverage and could further improve by addressing problematic areas through outcomes-based innovation and data analytics infrastructure, according to commentary published...

Tufts Health Plan Launches Four Medicaid ACO Partnerships

by Thomas Beaton

Tufts Health Plan has signed contracts to form Medicaid accountable care organizations (ACOs) with Atrius Health, Beth Israel Deaconess Care Organization, Cambridge Health Alliance, and Boston Children’s Hospital ACO, according to a press...

CMS: Payers Will Have More Time to File 2018 Health Plan Rates

by Thomas Beaton

Payers still debating how uncertainty over cost-sharing reduction (CSR) subsidies will alter their insurance prices now have more time to submit 2018 health plan rates, CMS announced in a letter to insurers. While the letter says there's...

Explaining Out-of-Pocket Costs May Ease Cancer Care Stress

by Thomas Beaton

Patients who are not prepared for the magnitude of their out-of-pocket costs for cancer care are more likely to be distressed and less likely to pay their bills than other individuals, according to a research letter published in JAMA Oncology....

As ACA Debate Lingers, Non-Marketplace Members Present Risks

by Thomas Beaton

While much of the national debate over health insurance has focused on the options open to ACA marketplace enrollees, payers should be careful not to neglect coverage choices for their private plan customers, who tend to be healthier and wealthier,...

Payers May Be Neglecting a Growing Medicare Advantage Market

by Thomas Beaton

Payers may be able to secure more of the growing Medicare Advantage (MA) marketplace by expanding their member messaging efforts and improving consumer education about what the supplementary plan has to offer, according to a new J.D. Power survey....

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