Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Value-Based Care News

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

July 17, 2018 - 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 cost stop-loss insurers $935.3 million. Most claims ranged between $1 and $1.5 million per individual, but 21 claims exceeded $2 million and a handful to...The top five most expensive treatments were mainly for blood diseases. The most expensive drug on the list was Yervoy, a cancer treatment. Large employers are more likely to have a higher number of high claims costs than smaller employers. The team found that 39.9 percent of employers with 5000 or more workers had at least one employee with claims exceeding $1 million. Less than 0.5 perc...The likelihood of an employer filing a stop-loss claim for cancer related tumors is 50.7 percent, meaning that payers sponsoring stop-loss insurance will likely have to cover some form of cancer care for half of their employer clients. Additionally, 71.1 percent of employers will file a stop-loss claim for one of the top ten most expensive conditions. The team suggested that employers us...


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How Payers Can Succeed Under Updated 2019 HEDIS Measures

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The Healthcare Effectiveness Data and Information Set (HEDIS) provides 90 percent of America’s health plans with the ability to directly compare performance across the national stage.   Currently, the HEDIS set contains 92 measur...Some of the changes to some of the requirements around preventive care and chronic disease management for 2019 may require payers to work with their contracted providers to ensure delivery of care, while others will alter the way payers rep...

BCBSA Adds Opioid Abuse Accreditation to Treatment Facilities

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The BlueCross BlueShield Association has announced a new accreditation program for opioid abuse treatment centers as a larger part of the organization’s mission to combat the US opioid crisis. In 2013, only 22 percent of treatment fac...

Medicare Advantage Star Ratings Tied to Member Socioeconomic Strata

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Medicare Advantage (MA) health plans with a greater proportion of socioeconomically challenged members are more likely to have lower star ratings, according to new research from Brown University. Insufficient risk adjustment criteria in the...

Transitional Health Insurance Plays Key Role in Coverage

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Transitional health insurance, otherwise known as a short-term health plan, is a temporary insurance policy intended to provide stop-gap coverage when an individual is in between ACA compliant policies.  The National Association of Ins...

NCQA Updates, Adds HEDIS Performance Measures for Plan Year 2019

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The National Committee for Quality Assurance (NCQA) has released updates to its HEDIS performance measures for plan year 2019. The refresh includes several new measures to guide population health management initiatives, as well.   NCQA...

Highmark BCBS Saves $260M Using Value-Based Reimbursement

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Highmark BlueCross BlueShield has saved $260 million in avoidable care costs by using value-based reimbursement and provider performance standards to hold healthcare organizations accountable for improving beneficiary outcomes. Highmark&rsq...

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

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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 out ...

Narrow Networks, Customer Satisfaction Contain Payer Spending

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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 employer-sponsored ...

Beneficiaries Want More Holistic Health, Wellness Benefit Options

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Health plan beneficiaries are increasing their demand for holistic health and wellness benefits, which can help payers deliver value and improve outcomes, according to a new report from Aetna. The Health Ambitions Study found that beneficia...

Customer Service is Primary Driver of Health Plan Satisfaction

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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 pre...

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

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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 Fi...Pay-for-performance models are the most developed value-based payment models in the industry, followed by global payment, prospective bundled payment, population-based, and retrospective bundled payment models. Value-based payment models ar...

Quality Analytics, Risk Adjustment Tools Prep Payers for Success

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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 collaboratio...The most comprehensive risk adjustment solutions include Pulse8, Talix, Invalon, Verscend, and Change Healthcare. These technologies offer coding training, risk adjustment validation compliance, EHR integration, and customized member health...

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

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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 paye...

Helping Payers Implement Value-Based Hospital Reimbursement

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Hospitals generate some of the largest revenues and create exceptionally high costs for payers, which combine open the possibility for value-based hospital reimbursement programs to control spending.        In March 2018...

First Steps for Payers Developing Value-Based Care Initiatives

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Successful value-based care initiatives require payers to learn which populations experience a high prevalence of chronic disease, where their organizations overspend, and how value-based contracting can solve these problems. Carefully asse...

Adding Telehealth, Remote Care Benefits into Health Plan Options

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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 ...

Commercial Health Plan Customer Satisfaction Remains Steady

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Commercial health plan customer satisfaction rates remained stable from 2017 to 2018, but payers still have a number of opportunities to improve their customer service and beneficiary education, according to a new JD Power consumer survey. ...

Improving Health Plan Customer Service Through Technology

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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...

How Payers Can Address Food Insecurity among Plan Beneficiaries

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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...

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