Value-based healthcare
Value-based care is a reimbursement model wherein payers compensate providers based on key metrics for care quality, care coordination and health outcomes. Value-based care aims to reduce healthcare costs and improve patients’ experience and health by using health information technology for data collection, analysis and sharing among providers.
Top Stories
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05 Dec 2024
5 pillars that underpin payer population health strategies
The healthcare system faces many challenges, but by focusing on these five pillars, payers can establish holistic and effective population health strategies. Continue Reading
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05 Aug 2024
Members rarely challenge coverage denials, surprise billing
Only 45% of individuals who received a surprise bill challenged it and only 43% of those who were denied coverage appealed the decision. Continue Reading
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01 Jul 2024
A VBC approach to improving pediatric behavioral healthcare access
Behavioral healthcare access for children and adolescents is lacking, but payers can use value-based care systems to increase and optimize referral opportunities. Continue Reading
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24 Jun 2024
How to accelerate value-based care despite looming healthcare crisis
Centering provider and member experience will be key to accelerating value-based care in the coming years. Continue Reading
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17 Jun 2024
Keys to success in the Medicare Advantage health equity index
The Medicare Advantage health equity index may not go into effect until 2027, but it will still affect payer strategies in 2024. Continue Reading
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10 Jun 2024
How Inaccurate Provider Data from Payers Impacts Access to Care
When payers’ online provider information is wrong, it may impact not only members’ access to care but also the level of member-payer trust. Continue Reading
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15 Feb 2024
7 Out of 10 Americans Struggling With Medical Debt Owe Over $1,000
Medical debt in the US amounted to at least $220 billion in 2021, with certain demographics seeing a higher likelihood of struggling to cover care. Continue Reading
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25 Jan 2024
A Look Inside the Four Most Common Value-Based Care Arrangements
Payers have several different value-based care arrangements they can offer, including pay-for-performance programs, bundled payment models, and capitation. Continue Reading
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28 Nov 2023
Medicare ACO Enrollment Did Not Improve Mental Healthcare Outcomes
New ACO enrollment was associated with a 24.4 percent lower likelihood of Medicare beneficiaries having an E/M visit for mental healthcare services. Continue Reading
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22 Nov 2023
Understanding Chronic Kidney Disease Coverage, VBC Opportunities
Innovative and comprehensive chronic kidney disease coverage presents an opportunity to lower healthcare spending in the US. Continue Reading
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20 Nov 2023
Humana’s Value-Based Care Plans Improved Health Outcomes for MA Members
In addition to improving health outcomes, Humana’s Medicare Advantage value-based care plans generated $8 billion in cost savings in 2022. Continue Reading
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02 Oct 2023
How to Evaluate Benefits to Ensure Health Equity for All Members
Employers and health insurers need to evaluate their plans’ benefit designs for health equity to ensure that members are getting equal actuarial value. Continue Reading
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14 Sep 2023
How Do Payers Approach Care Management Strategies, Technologies?
Leveraging EHR systems, telehealth tools, and data analytics can help payers improve care management strategies. Continue Reading
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23 Aug 2023
Employers Grapple with Workforce Mental Health Needs Post-Pandemic
Mental health issues were the most commonly cited impact of COVID-19 and mental health initiatives were the highest priority for employers looking toward 2024. Continue Reading
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18 Aug 2023
CQMC Revises Quality Measures, AHIP Advocates for Better Alignment
The quality measure changes touched eight out of the ten core measure sets and could influence CMS quality measurement. Continue Reading
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17 Aug 2023
Blue Shield of CA Launches Value-Based Pharmacy Model to Lower Drug Costs
Blue Shield is working with five drug companies to launch the value-based pharmacy model and lower drug costs for members. Continue Reading
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09 Aug 2023
How Payers Can Reduce Emergency Department Admission Rates, Costs
To reduce emergency department admission rates, payers can implement virtual care, machine learning, and value-based care strategies. Continue Reading
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02 Aug 2023
4 Essential Components of Chronic Disease Management Strategies
Chronic disease management requires strong disease management programs, care coordination, member education, and preventive care. Continue Reading
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25 Jul 2023
Value-Based Care and Fee-For-Service: What’s the Difference?
Health plans reimburse providers based on quantity under fee-for-service models but prioritize quality in value-based care models. Continue Reading
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20 Jul 2023
Common Utilization Measures That Impact Value-Based Care Efforts
Utilization measures such as emergency department use, hospital readmissions, and preventive care use are crucial to improving quality of care. Continue Reading
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18 Jul 2023
Unnecessary Utilization in CO Leads to $134M in Healthcare Spending
The share of healthcare spending on low-value care was highest in Colorado’s commercial health plans. Continue Reading
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07 Jul 2023
4 Key Inflators That Are Fueling Medical Cost Trends, Pricing
Inflation, reimbursement rates, pharmaceutical pricing, and consolidation drive medical cost trend, but payers can take action. Continue Reading
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05 Jul 2023
How Long-Term Health Plan Enrollment Supports Value-Based Care
Long-term health plan enrollment can allow for better investments that drive lasting positive health outcomes. Continue Reading
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20 Jun 2023
How Value-Based Purchasing Program Design Influences Outcomes
Higher-intensity value-based purchasing programs were more likely to have positive outcomes for quality process, quality utilization, and spending reduction measures. Continue Reading
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15 Jun 2023
End of COVID-19 Policies Will Influence National Healthcare Spending
National healthcare spending will grow on average 5.4 percent each year from 2022 to 2031. Continue Reading
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05 Jun 2023
6 Key Payer Benefits that Support Behavioral Health Prevention
Along with a strong provider network, payers can use these six strategies to promote behavioral health prevention. Continue Reading
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17 May 2023
6 Ways That Health Plans Can Influence A State’s Health Equity
A state’s health equity can improve when health insurance companies take ownership of the process and implement one or more of these six methods. Continue Reading
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16 May 2023
Delivering on the Promise of Value-Based Care
It’s been more than a decade since value-based care started making waves in healthcare. And from the start, there have been three core goals of the new model... Continue Reading
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21 Apr 2023
CVS Health ACO Partnership Expands Value-Based Care in Long Island
The collaboration will provide value-based care, personalized support, and care coordination services to 40,000 Medicare beneficiaries in Nassau and Suffolk counties. Continue Reading
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17 Apr 2023
How Specialty Pharmacies Compare to Provider, Hospital on Drug Pricing
Drug pricing is a major concern among employers and insurers, but research has highlighted a possible price control mechanism. Continue Reading
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11 Apr 2023
Long-Term COVID-19 Symptoms Associated with Higher Unmet Needs
Cost of care and access to care barriers were higher among patients who experienced post-COVID-19 conditions and led to unmet needs. Continue Reading
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10 Apr 2023
58% of Payers Use Outcomes-Based Contracts for Prescription Drugs
While 10 percent of payers had between two and five outcomes-based contracts in place in 2022, 35 percent had 10 or more contracts. Continue Reading
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28 Mar 2023
4 Changes to OMB Data Regulations That Could Improve Health Equity
Blue Cross Blue Shield Association and the National Minority Quality Forum shared four changes to OMB’s Directive No. 15 that could improve data collection and health equity in the US. Continue Reading
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14 Mar 2023
CA VBID Program Boosted Primary Care Use, Contained Healthcare Costs
Members enrolled in the value-based insurance design plan saw increased primary care use, leading to higher out-of-pocket healthcare costs for outpatient care but lower inpatient costs. Continue Reading
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08 Mar 2023
UnitedHealthcare Provides Funding to Support Workforce Development
The insurer aims to address multigenerational poverty in Georgia through a large workforce development grant that will be used to provide employment resources and health screenings. Continue Reading
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02 Mar 2023
The Cost of Cancer Should Reflect Impacts on Wellbeing, Productivity
On top of out-of-pocket healthcare spending and high medical bills, young adults and adolescents with cancer face loss of wellbeing and productivity as the cost of cancer. Continue Reading
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10 Jan 2023
Going Beyond Benefits: How Employers Can Assess, Create Wellness Culture
Surveys have demonstrated that employers and employees do not share the same opinion on employer mental health initiatives, so how can employers improve wellness culture? Continue Reading
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04 Jan 2023
How Insulin Costs Vary Across Medicare, Medicaid, Private Plans, Uninsurance
Insulin costs take up a more significant share of prescribed medicine expenditures and overall healthcare spending for Medicare beneficiaries than for individuals with other types of insurance. Continue Reading
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03 Jan 2023
Top Predictions for Health Insurers, Employers in the New Year
Experts’ top predictions indicate that insurers and employers will face high costs and other challenges but will also find opportunities in places like specialty pharmacy. Continue Reading
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27 Dec 2022
Improving Accessibility for Spanish-Speaking Seniors in Medicare Advantage
Spanish-speaking seniors face a variety of challenges in navigating Medicare, but payers can take steps to demystify the system by providing authentic Spanish-speaking services. Continue Reading
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22 Dec 2022
How Employers Can Achieve a Fair Price in Hospital Negotiations
With healthcare costs skyrocketing, it is time for employers to take the reins on negotiating hospital prices to achieve a fair price. Continue Reading
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21 Dec 2022
Status of Women’s Health Across Insurance Types in 2022
Women’s health and their experience of the healthcare system differed based on whether they were insured or uninsured. Continue Reading
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20 Dec 2022
Payer, Provider Value-Based Care Contract Targets Equity, Population Health
The value-based care contract aims to improve health among Black Philadelphians and integrate behavioral healthcare and physical care, among other goals. Continue Reading
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08 Dec 2022
Top 3 Major Trends in National Health Outcomes Measures
National health outcomes measures continue to suffer from the coronavirus pandemic’s influence. Continue Reading
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30 Nov 2022
GA Payer Helps Providers Improve Access to Care for Disabled Individuals
Facilities that are not designed to fit the needs of disabled individuals can limit access to care for this member population, but an initiative in Georgia is seeking to resolve that issue. Continue Reading
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16 Nov 2022
2022 RI Life Index Finds Social Determinants of Health Barriers in RI
The RI Life Index, now in its fourth year, revealed a decline in perceived community, quality of life, and social determinants of health factors in 2022. Continue Reading
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15 Nov 2022
Major Payers Spent Less Than 1% of 2021 Income on Social Determinants of Health
Six payers with the largest market shares may have spent on average 0.67% of their income in 2021 on social determinants of health, but in 2020 that amount jumped to 1.6 percent. Continue Reading
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02 Nov 2022
Value-Based Care Implementation Requires Investments, Collaboration
Rocky Mountain Health Plans in Colorado implemented its value-based care model over a decade ago, but continuous success hinges on collaboration between stakeholders and investments in key resources. Continue Reading
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24 Oct 2022
Offering Easy Access to Care Is Key to Positive Member Experience, Retention
In order to keep their members, payers have to provide a positive patient experience by enabling easy navigation through the healthcare landscape. Continue Reading
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17 Oct 2022
How One Payer Expanded the Boundaries of Maternal Healthcare Benefits
BCBSM expanded its maternal healthcare benefits to encompass more of the childbirth and child-rearing journey. Continue Reading
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04 Oct 2022
Home Health Value Based Purchasing Model Slightly Improved Spending, Care
Home health value-based purchasing demonstrated slight decreases in certain types of utilization and also generated Medicare savings. Continue Reading
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20 Sep 2022
Out-of-Pocket Healthcare Spending for Generics Rose from 2011-2019
As generics moved to higher tiers, out-of-pocket healthcare spending for generics increased for patients. Continue Reading
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15 Sep 2022
Partnership Aims to Improve Health Equity with Clinical Intervention
Humana and the Chartis Group aimed to improve health equity in South Florida and Texas with cultural humility and bias training. Continue Reading
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14 Sep 2022
Medicare Advantage Boasts Fewer Low-Value Care Services Than FFS Medicare
The value-based care model that is common throughout Medicare Advantage seemed to be key to producing fewer low-value care services. Continue Reading
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08 Sep 2022
Concerns about Cost of Healthcare Supersede COVID-19 Concerns in MA
The cost of healthcare is of greater concern to Massachusetts residents than quality of care and access to care. Continue Reading
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01 Sep 2022
Emergency Department Patients Are More Likely to Have Chronic Diseases
Seniors who ended up in the emergency department were more likely to have multiple chronic diseases that can lead to severe coronavirus symptoms. Continue Reading
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31 Aug 2022
Top 3 Social Determinants of Health Barriers Among Seniors
Identifying the most prominent social determinants of health barriers among seniors can help payers shape their Medicare Advantage benefits to match seniors’ needs. Continue Reading
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25 Aug 2022
7 Ways That Payers Help Members Manage Their Mental Health Needs
Seven themes emerged from a list of payers’ efforts to help members manage their mental health needs. Continue Reading
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19 Aug 2022
3 Major Payers Take Action on Social Determinants of Health
Elevance Health, Aetna, and Cigna health plans have launched various social determinants of health initiatives to improve members’ quality of care. Continue Reading
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15 Aug 2022
Healthcare Often Forces Patients to Make Financial Sacrifices
Recent research showed that 38 percent of American adults limited automobile activities and food consumption to ensure payment of medical bills. Continue Reading
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10 Aug 2022
Hepatitis C Treatment Rates Reveal Care Disparities in Public, Private Coverage
Care disparities for hepatitis C may result in differences in timely diagnosis and treatment based race, age, coverage type, and gender. Continue Reading
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01 Aug 2022
NCQA Adds New HEDIS Quality Measures to Improve Race, Gender Health Equity
NCQA introduced new quality measures related to health equity in race and ethnicity stratification as well as gender inclusivity. Continue Reading
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28 Jul 2022
How Family Income Impacts Out-of-Pocket, Catastrophic Spending on Insulin
Catastrophic spending on insulin is highest for Medicare beneficiaries in part because their family income—after subsistence spending—is so low. Continue Reading
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27 Jul 2022
Top Payer Strategies Around Payment Models for Advanced Therapies
Payment models for advanced therapies have to incorporate well-defined outcomes measures, ensure that the drug’s price reflects its value, and comply with state and federal regulations. Continue Reading
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25 Jul 2022
More than Half of Americans Have Low Health Insurance Literacy
Americans reported misconceptions about health savings accounts, special enrollment periods, and dependent coverage, indicating low levels of health insurance literacy. Continue Reading
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21 Jul 2022
Key Opportunities, Action Steps for Race, Ethnicity Data Collection
Healthcare leaders agree that race and ethnicity data collection needs to improve and now a group of stakeholders has highlighted key opportunities to do so. Continue Reading
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12 Jul 2022
Health Net Shares Payer Best Practices for Bolstering Community Support
Reflecting on its participation in a California Medicaid initiative, the payer offered insight into how to drive community support benefits. Continue Reading
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11 Jul 2022
Value-Based Care in Diabetes Care Management Calls for Policy Changes
Value-based care models have had mixed effects in diabetes chronic disease management, but certain policy changes could amplify the impact. Continue Reading
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11 Jul 2022
How Payers Can Deliver Value Through Care Management Models
Care management models need to improve care quality while cutting costs, but as member experience becomes more important payers must adapt their care models. Continue Reading
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30 Jun 2022
Payer Uses Value-Based Care to Improve Musculoskeletal Disease Care
The partnership aims to help providers succeed in value-based care to improve healthcare affordability for treating bone, muscle, and ligament injuries and disorders. Continue Reading
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28 Jun 2022
Health Insurance Is The Third-Highest Living Expense For Americans
Health insurance premiums take up 10.69 percent of the average American’s annual salary, the highest living expense after rent and childcare. Continue Reading
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24 Jun 2022
Payers Missing the Mark on Digital Member Experience, Satisfaction
Many payers are failing to track member experience journeys, making it harder for organizations to improve digital experiences. Continue Reading
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15 Jun 2022
How States Can Improve, Increase Race and Ethnicity Data Collection
Race and ethnicity data collection is critical for advancing health equity, but many states need to improve their processes. Continue Reading
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13 Jun 2022
Humana Expands Home Healthcare Model to Serve Virginia
Humana enhanced its identity by expanding the boundaries of onehome, a home healthcare model the payer acquired in 2021. Continue Reading
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07 Jun 2022
Payer Health Equity Elusive for LGBTQ+, But Improvements Are Ahead
A survey indicated that one-third believe that coverage is improving for the LGBTQ+ population, however, payer health equity remains out of reach. Continue Reading
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06 Jun 2022
How Loneliness Impacts Employees As A Social Determinant of Health
The report found that loneliness, a prevalent social determinant of health, was particularly prevalent among employees with mental health conditions, along with a variety of other factors. Continue Reading
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06 Jun 2022
More Consumers Find Transparency Tools Accessible, Useful in 2022
Transparency tools helped members manage their healthcare spending, informed their decision-making, and supported care navigation. Continue Reading
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31 May 2022
Anthem Foundation Funds Substance Use Disorder Programs
Anthem Foundation donates $13 million to fifteen different organizations with substance use disorder programs to improve mental healthcare access. Continue Reading
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25 May 2022
Key Preventive Care Services Recommendations from USPSTF in 2022
Aspirin as a preventive measure against heart attack or stroke and screening for COPD are two preventive care services on which USPTF issued final recommendations. Continue Reading
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17 May 2022
UHG Report Highlights Mental Healthcare Needs Among Seniors
Seniors’ drug-related deaths, early death rates, and the need for mental healthcare saw significant increases over the last decade. Continue Reading
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16 May 2022
How Payers Can Move Providers Along Value-Based Care Continuum
As providers move along the value-based care continuum, payers can offer financial and technical support, help them pursue primary care transformation, and present further research. Continue Reading
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13 May 2022
What Are Employer Sponsored Wellness Programs?
Employer sponsored wellness programs can address any of five or more domains of wellness, including social, financial, and environmental wellness. Continue Reading
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03 May 2022
MN Uninsurance Rate Drops, But Racial Disparities Persist
Racial disparities in coverage worsened in Minnesota, with the uninsurance rate rising to 7.6 percent for people of color and American Indians. Continue Reading
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02 May 2022
CVS Health: More Americans Value Mental Health Conversations
The survey found that an increasing share of adults values discussing mental health with a clinician, friend, family member, or even a coworker. Continue Reading
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29 Apr 2022
OIG Suggests Changes to MA Prior Authorizations, Payment Requests
Prior authorizations and payment requests in Medicare Advantage have been inaccurately denied or delayed, resulting in profits for health plans and problems for patients and providers. Continue Reading
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28 Apr 2022
CA Medicaid Plan Seeks to Streamline Pay for Performance Model
Pay for performance models have long been one of the most popular types of reimbursement models, used to boost quality of care. Continue Reading
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27 Apr 2022
BCBSA Outlines Next Steps for Health Equity Data Standardization
Health equity data collection lacks standardization and BCBSA has called on the healthcare industry to take three steps to rectify this. Continue Reading
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26 Apr 2022
Low Socioeconomic Status Negatively Impacted Healthcare Delivery
Low socioeconomic status was associated with higher rates of potentially preventable events for Medicare beneficiaries, such as hospital readmissions and emergency department visits. Continue Reading
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25 Apr 2022
Humana Outlines Social Determinants of Health Industry Progress
CMS, Humana, and other payers have taken a variety of approaches to advancing social determinants of health data collection and utilization. Continue Reading
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25 Apr 2022
BCBSRI Joins Global Capitation Model, Starts 2022 RI Life Index
The payer will enter into a global capitation model with an ACO and will glean data on social determinants of health in Rhode Island through the index survey. Continue Reading
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22 Apr 2022
Top Employer Strategies for Health Equity in Obesity, Diabetes
Health equity is integral to the success of employers’ obesity and diabetes prevention and management benefits. Continue Reading
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21 Apr 2022
4 ACA Marketplaces Take Action to Advance Health Equity
Four states have taken steps to promote health equity on their Affordable Care Act marketplaces. Continue Reading
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13 Apr 2022
7 Challenges, Costs of Utilization Management for Employers
Utilization management strategies may be intended to lower costs for employers and employees, but they can result in restricted access to care and higher member costs. Continue Reading
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31 Mar 2022
Uninsured Adults Less Likely to Access Mental Healthcare Services
Uninsured adults and insured adults without a usual source of care were most likely to have unmet needs and go without mental healthcare services. Continue Reading
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28 Mar 2022
CQMC Finds Quality Measurement Gaps, Supports Digital Measures
The report found seven areas in which payers and healthcare stakeholders can fix quality measurement gaps, including health equity and digital quality measures. Continue Reading
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21 Mar 2022
Value-Based Care Models That Could Lower Maternal Care Costs
The financial cost of maternal care is high and disparities in outcomes based on a patient’s race persist, but value-based care models could help address these concerns. Continue Reading
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21 Mar 2022
Privately Insured Catheter Users Incurred High Out-of-Pocket Costs
Catheter users on private health plans paid around $1,600 in average annual out-of-pocket costs, while publicly insured catheter users spent $530. Continue Reading
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15 Mar 2022
Out-of-Pocket Healthcare Spending Higher for Pregnant People
Low-income pregnant people who received private health insurance coverage were most likely to experience catastrophic out-of-pocket healthcare spending. Continue Reading
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09 Mar 2022
Obstacles to Covering Precision Medicine Multicancer Screenings
Multicancer screening tests are a form of precision medicine that may reduce low value spending, but payers face a number of challenges in deciding whether to cover them. Continue Reading
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07 Mar 2022
Consumers Emphasize Insurer Role in High Healthcare Spending
While consumers wanted to see more transparency across the major healthcare stakeholders, they stressed the personal impact of insurance-related healthcare spending. Continue Reading
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28 Feb 2022
Uninsurance Rate Among Black Americans Dropped 8% Under ACA
The uninsurance rate among Black Americans remains higher than the uninsurance rates in White communities, but it has improved over the last decade. Continue Reading
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24 Feb 2022
National Healthcare Spending, Prices Saw Modest Increase in 2021
During the second year of the pandemic, national healthcare spending, service prices, and healthcare employment numbers fluctuated but increased overall. Continue Reading