In the News
Stories and trends changing the healthcare landscape
Medicaid Changes and Challenges for Health Plans
There are both immediate and longer-term changes that set forth an uncertain and multi-dimensional framework for health plans and provider organizations to consider as they think about individuals served and ways to plan for and/or mitigate the health care consequences for the diverse groups of individuals served who may be at risk.
Combatting Fraud in Healthcare
Fraud in healthcare billing and payment continues to be a serious risk for payers and providers alike. Billions of dollars are misappropriated every year resulting in increasing costs throughout the healthcare delivery system.
Public and private payers are serious about rooting out fraud, waste, and abuse in the health care system wherever it may occur, given the magnitude of the problem.
Medicare Advantage – Part 2
Headwinds and Strategies to Weather the Storm
The Medicare Advantage market appears to be at a critical crossroads. The past few years have seen unprecedented enrollment growth, fueled by a rapidly increasing over 65 population and a favorable regulatory environment. The unprecedented growth from prior years has now slowed down and conflicting trends converging on Medicare Advantage organizations are expected to continue to result in more tempered growth going forward.
Precision Medicine – Part 3
Leveraging Social Determinants of Health
Social determinants of health (SDOH) refer to the non-medical factors that influence health outcomes. These factors are shaped by the environments in which people live, grow, work, play, and age, as well as the broader societal systems that impact daily life. SDOH encompasses a wide range of conditions and influences that can either promote or hinder health, well-being, and quality of life.
These determinants often contribute to health disparities, where certain groups experience poorer health due to unfavorable social or economic conditions. Addressing SDOH is critical for improving health equity and reducing health disparities across populations. Programs and policies aimed at improving SDOH, such as increasing access to education, healthcare, and economic resources are essential for fostering better health outcomes for all.
Precision Medicine – Part 2
Data, Applications, Benefits and Challenges:
Much of the success in reducing morbidity and mortality over the past half century has been due to earlier detection of disease, in tandem with public health measures such as smoking cessation and weight management; as well as wider application of proven therapies for primary and secondary prevention.
Fast forward to today, the significant advances in data collection and data platforms (including the advent of AI and sophisticated algorithms) have raised interest in leveraging expanded data and information to create a more comprehensive (all-encompassing) view of individual risk markers and other health risk characteristics outside the realm of more traditional clinical (biometric) measures.
Value-Based Care – Article 1 – December 2024
Value-Based Care (VBC) is a healthcare model that ties healthcare providers’ compensation to the quality, equity, and cost of care they deliver. The model focuses on improving patient outcomes, such as health quality and satisfaction, while also promoting cost-effective care. Providers are incentivized to deliver better care by focusing on the overall health of patients, addressing preventive care, and coordinating treatment. This model contrasts with the traditional fee-for-service system, where providers are paid based on the volume of services delivered rather than patient outcomes.
CMS Pre-Authorizations – November 2024
CMS Interoperability and Prior Authorization Final Rule Synopsis
The Centers for Medicare & Medicaid Services (CMS) changed its prior authorization rules to simplify and digitize the process, and to reduce the burden on each of the three legs in the healthcare delivery tripod: patients, providers, and payers. In particular, CMS aims to reduce administration, simplify and accelerate the process, and introduce standardization across payers.
It is critically important for providers and especially payers to get ahead of these changes by assessing processes and the technology necessary to support the rules change and ensure compliance.
Precision Medicine – Part 1 – September 2024
Precision Medicine as key driver of next generation personalized health care
The term “Precision Medicine” refers to the tailoring of clinical and other health care-related interventions based upon an individual’s unique make-up and circumstances. While personalization of care has long been the underpinning of best practice medicine, personalized care and Precision Medicine are not exactly synonymous. Precision Medicine is an expanded approach that uses information about an individual’s biological, environmental, and lifestyle characteristics to guide decisions related to their medical and health management.
Payment Integrity 101 – Article 3 – June 2024
Payment Integrity Evolution
Over the past decade, the healthcare industry has seen payment integrity evolve from an under-resourced operational niche to a strategic asset that is central to the overall management of medical expense. A paradigm shift is underway, wherein many payers are recognizing that the status quo will not suffice in a volatile, disruptive market where, among other things, technology is advancing rapidly. Many are at the initial stages of fully understanding and implementing elements of a comprehensive future vision for payment integrity efforts, which in addition to dedicated analytic staff, comprise a team committed to ideation and innovation. Vital measures to track and drive performance of Payment Integrity (PI) initiatives, including the use of industry benchmarks and annual goal setting are gaining traction.
Payment Integrity 101 – Article 2 – June 2024
Guiding Principles: Payment Integrity as a Strategic Enterprise Solution
Today’s technology innovations and workforce challenges (need to drive toward greater efficiency) are prompting payers to take a closer look at payment integrity with an eye toward a more strategic framework. More and more payers are recognizing that the status quo will not suffice in a volatile, disruptive market where change is happening with increasing speed.
Over the past decade, the healthcare industry has seen payment integrity evolve from an under-resourced operational niche to a strategic asset that is central to the overall management of medical expense, in addition to efforts to improve quality of care and foster mutually satisfying provider relations. Let’s look at some guiding principles establishing Payment Integrity as a strategic asset.
