Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Spending

Nearly 20% of Employees Have Inpatient Out-of-Network Claims

August 14, 2018 - Approximately twenty percent of employees with insurance had at least one out-of-network claim for inpatient care, according to a Peterson-Kaiser Tracker analysis. Employees with out-of-network provider bills may experience increased stress due to the cost of healthcare because they are largely responsible for out-of-network costs. In 2016, 15.5 percent of all inpatient admissions...


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Managed Care Accounted for 38% of Medicaid Spending in 2012

by Thomas Beaton

Medicaid managed care accounted for 38 percent of total Medicaid spending in 2012, according to a Congressional Budget Office analysis. The report found that the majority of states in the US have implemented some form of a managed care...

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...

CMS Proposes Site-Neutral Payments, Drug Price Negotiation

by Thomas Beaton

CMS has proposed a rule that would expand the use of site-neutral payments and improve the drug price negotiation process with manufacturers in order to reduce Medicare’s overall spending. The new rule would allow Medicare to...

About 90% of Large, Mid-Size Employers Offer Medical Benefits

by Thomas Beaton

Close to 90 percent of employees in large and mid-size private businesses are offered medical benefits, according to data released by the Bureau of Labor Statistics. Larger businesses tend to see higher participation in employer-sponsored...

High Dollar Claims Rise by 87% in Employer-Sponsored Stop-Loss Insurance

by Thomas Beaton

The number of employer-sponsored stop-loss insurance claims of $1 million or more grew by 87 percent from 2014 to 2017, according to a new analysis from Sun Life Financial. Over the four-year period, 634 employees with $1 million claims...

Health Plan Cost Sharing, Deductibles Outpace Members’ Wage Growth

by Thomas Beaton

Health plan cost sharing and deductible spending have outpaced employee wage growth in the last ten years, according to data released by the Peterson-Kaiser Health System Tracker. Employees’ total financial responsibility increased...

Can Retail Clinics Improve Patient Access, Reduce Costs for Payers?

by Thomas Beaton

Retail clinics are gaining in popularity among patients looking for quick, convenient care for minor ailments. Kiosks and no-appointment-needed offices located in corner pharmacies and big box stores have the potential to keep patients...

Partners HealthCare to Self-Insure 100K Employees

by Thomas Beaton

Partners HealthCare has announced it will self-insure 100,000 of its employees, transitioning coverage from BlueCross BlueShield of Massachusetts to its own Neighborhood Health Plan, according to The Boston Globe. “Neighborhood...

MedPAC: Value-Based Payment, Post-Acute Care Boost Medicare Savings

by Thomas Beaton

MedPAC has advised Congress that value-based payment reform and encouraging the use of post-acute care can help the Medicare program increase savings and improve beneficiary outcomes, the group said in a new report. Revisions to payment...

Narrow Networks, Customer Satisfaction Contain Payer Spending

by Thomas Beaton

Payers can curb spending on medical care by investing in narrow networks and customer satisfaction tools, says a new PricewaterhouseCoopers (PwC) Health Research Institute (HRI) analysis. PwC found that medical costs for...

Amazon, Berkshire, JPMorgan Name Atul Gawande Healthcare CEO

by Thomas Beaton

Amazon, Berkshire Hathaway, and JPMorgan Chase have named Atul Gawande, a surgeon at Brigham & Women’s Hospital, as the CEO of their joint healthcare company. The company will be headquartered in Boston, Massachusetts. Gawande...

Customer Service is Primary Driver of Health Plan Satisfaction

by Thomas Beaton

Health plan members are seeking high-quality customer service experiences from their insurers, and will use positive interactions to make decisions about continued loyalty, according to a new Forrester analysis emailed to members of the...

Value-Based Payment Adoption Drives 5.6% Reduction in Care Costs

by Thomas Beaton

Payers that implemented value-based payment models reduced healthcare costs by an average of 5.6 percent, improved provider collaboration, and created more impactful member engagement, according to a new study from Change Healthcare. The...

Automated Claims Administration Could Bring Billions in Savings

by Thomas Beaton

Automated claims administration could bring around $11 billion in savings to health plans and providers if the technology is implemented more broadly, according to the latest CAQH Index. Payers should encourage providers to adopt...

Quality Analytics, Risk Adjustment Tools Prep Payers for Success

by Thomas Beaton

Quality analytics and risk adjustment technologies are effective solutions for payers when these tools can structure claims and clinical information into actionable models, identify multiple risk indicators, and foster provider...

Humana, Roche Diagnostics Face $45M Federal Kickback Lawsuit

by Thomas Beaton

Humana and Roche Diagnostics will face a $45 million federal kickback lawsuit after a whistleblower filed a False Claims Act violation, which alleges Roche tried to entice Humana financially to secure access to the payer’s business...

Private Payers Deny Hepatitis C Drug Coverage to 52% of Members

by Thomas Beaton

Private payers denied Hepatitis C drug coverage to 52.4 percent of commercially insured beneficiaries from 2014 to 2017, according to new research from the Perelman School of Medicine at the University of Pennsylvania. Hepatitis C drug...

AHIP, BCBSA, AMA Join to Improve Public, Private Payer Ecosystem

by Thomas Beaton

The Partnership for America’s Health Care Future (PAHCF), a newly formed coalition, consisting of leading healthcare provider societies and payer organizations, has committed to strengthening the nation’s private and public...

BCBS of TX Delays Non-Emergency ED Claims Review Policy

by Thomas Beaton

BlueCross BlueShield of Texas has delayed implementation of a claims review policy that would require HMO members to pay the total cost of an emergency department visit if the encounter is later deemed to be a non-emergency, according to a...

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