Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Payers

Handful of States Propose Lower ACA Premium Rates for 2019

by Thomas Beaton

Several states have announced lower ACA premium rates for 2019, bucking a national trend brought on by unstable markets and regulatory changes.   While early proposals from a number of states, including Virginia, Maryland, and...

Payers Sue to Collect 2017 Cost Sharing Reduction Payments

by Thomas Beaton

Payer organizations are exercising their right to use the court system to collect cost sharing reduction (CSR) payments that were not provided in the last quarter of 2017. A number of lawsuits are challenging the government’s...

CPC+ Model Offers Payers Insight into Population Health Management

by Thomas Beaton

CMS’s Comprehensive Primary Care Plus (CPC+) model may offer lessons and strategies for payers that want to increase primary care efficiency with population health management strategies. The CPC+ model is the nation’s largest...

How to Curb Adverse Selection in the Individual Health Plan Market

by Thomas Beaton

Maintaining a profitable individual health plan product is already challenging, but adverse selection can create additional problems that impede a payer’s ability to control health plan costs. Policies within the Affordable Care...

How Can Accreditation Programs Promote Health Plan Value?

by Thomas Beaton

Health plan accreditation programs can help payers highlight offerings that deliver on key quality, efficiency, and beneficiary satisfaction measures. Many health plans currently participate in the HEDIS performance set and receive...

How Capitated Payments Prompt Payer, Provider Innovation

by Thomas Beaton

The challenges of lowering care costs and improving healthcare quality may lead payers to consider the use of capitated payments as part of their value-based payment model strategies. Capitated payments are pre-arranged payments for...

Next Generation ACO Model Saved Medicare $62M in 2016

by Thomas Beaton

Next Generation Accountable Care Organizations (ACO) saved the Medicare program $62 million during their first year of operation in 2016, encouraging CMS to expand downside risk models across Medicare. Next Generation ACOs accept the...

Value-Based Care Slashes Per Member Per Month Costs in Kansas

by Thomas Beaton

BlueCross BlueShield of Kansas has seen significantly lower per member per month costs for beneficiaries participating in value-based care arrangements, including accountable care organizations (ACOs) and patient-centered medical homes...

Payers, Providers Create New Medicare Advantage Partnerships

by Thomas Beaton

New Medicare Advantage plans, many born of innovative partnerships between payers and providers, are creating more options for beneficiaries to supplement their existing coverage with high-value offerings. Commercial payers operating in...

Anthem, Walmart Partner for Over-the-Counter Drug Allowance

by Thomas Beaton

A new partnership between Anthem and Walmart will allow Medicare Advantage beneficiaries to purchase over-the-counter drugs and other drug store necessities with a plan allowance. Starting in January of 2019, Anthem beneficiaries will be...

CMS Tells States to Curb Silver-Loading with Off-Exchange Plans

by Thomas Beaton

CMS is asking state insurance departments to offer more off-exchange health plans in order to reduce silver-loading of qualified health plans (QHP). Silver-loading is the practice of raising premiums so that payers can earn larger federal...

CMS Processes State Medicaid Requests, Approvals 23% Faster

by Thomas Beaton

CMS has announced that an agency initiative to streamline state Medicaid approvals and state plan amendments (SPAs) has increased approval processing speed by 23 percent. In 2017, CMS sent a bulletin to state Medicaid programs informing...

Google Invests $375M in Oscar Health for Medicare Advantage

by Thomas Beaton

Google’s parent company, Alphabet, has invested $375 million in Oscar Health to help the tech-focused payer enter into Medicare Advantage markets by 2020, according to multiple news outlets, including Reuters. Oscar Health said in...

OH Medicaid Adopts Pass-Through Model for Managed Care Drugs

by Thomas Beaton

Ohio’s Medicaid program has issued a mandate that requires managed care health plans to re-negotiate pharmacy benefit manager (PBM) contracts to transition from a spread-pricing drug purchasing model to a pass-through model. The...

Commercial Payers See Promise in Diabetes Prevention Program

by Thomas Beaton

The Diabetes Prevention Program could offer commercial payers an impactful way to prevent chronic disease for beneficiaries, according to a new report from AHIP.   In 2012, AHIP recruited seven large payers to a pilot program which...

Medicare Advantage Part B Plans Can Use Drug Step Therapy

by Thomas Beaton

CMS is allowing Medicare Advantage (MA) health plans to implement step therapy protocols in order to decrease prescription drug spending. On January 1, 2019, MA health plans can apply step therapy guidelines for physician-administered...

AMA: CVS-Aetna Merger Would Reduce PBM Competition, Raise Prices

by Jennifer Bresnick

The American Medical Association is urging the Department of Justice to squash the proposed merger between CVS Health and Aetna.  The combined entity would drastically reduce competition in many pharmacy benefit management (PBM)...

Only 22% of Medicare Advantage Customers Aware of Star Ratings

by Thomas Beaton

Only 22 percent of Medicare Advantage (MA) beneficiaries are familiar with how star ratings work and increasing consumer awareness about star ratings would help beneficiaries choose high quality plans, according to a new Healthmine...

Provider Market Concentration Outweighs Payer Concentration

by Thomas Beaton

Healthcare provider systems tend to be bigger, more consolidated, and have more market share than payers in the same metropolitan areas, leaving some payers with less power to negotiate pricing and other contracts, according to the...

Centene, Ascension Partner for Medicare Advantage Offering

by Thomas Beaton

Centene and Ascension have partnered to offer a Medicare Advantage plan across multiple geographic markets in 2020.   Centene Chairman and CEO Michael F. Neidorff believes that the partnership will showcase effective strategies to...

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