Accelerating the Rise of Value-Based Care

July 7th, 2023|Categories: Featured, Industry News|Tags: , , , , , |

Enacting value-based care payment models has been a priority of payer and provider organizations in recent years, but the implementation has been uneven, with care centers serving underprivileged or vulnerable populations being left in the lurch. Helping close the gap is pivotal to reaching the US Centers for Medicare and Medicaid Services (CMS) goal of transitioning to value-based payment models for the majority of Medicaid and Medicare reimbursements.

Examining the Five Biggest Players in Medicaid Managed Care

July 7th, 2023|Categories: Featured, Industry News|Tags: , , , , |

With over 70% of Medicaid beneficiaries being enrolled in plans from managed care organizations (MCOs), managed care has become a major player in the American health insurance industry. A new article by the Kaiser Family Foundation (KFF) takes a look at five of the largest MCOs and how they are influencing the managed care landscape.

Biden Administration Rolls Back Limit on Short-Term Health Plans

July 7th, 2023|Categories: Featured, Industry News|Tags: , , , |

The Biden administration and the US Department of Health and Human Services (HHS) have put forward a proposed rule that would set the limit for short-term health insurance to 4 months, reversing a Trump-era rule that gave them durations up to one year with the chance of renewal. Democrats derided these forms of insurance as “junk insurance,” noting that although they are cheap, they have poor coverage and are only meant to serve as a stop-gap measure.

Alzheimer’s Drug Leqembi Gets Full FDA Approval and Medicare Coverage

July 6th, 2023|Categories: Featured, Industry News|Tags: , , , |

Eisai and Biogen’s Alzheimer’s treatment Leqembi (lecanemab) has received full approval by the US Food and Drug Administration (FDA). This marks the first full approval for an Alzheimer’s disease treatment in decades and clears the path to Medicare reimbursement, which previously required providers contribute data to a patient registry.

Healthcare Costs to Jump by 7% in 2024

July 3rd, 2023|Categories: Featured, Industry News|Tags: , , , , , |

A report by PwC projects that healthcare costs will rise by 7% next year. The report was based on interviews with major payer organizations covering over 110 million patients in the US. Estimated increases in costs are attributed to labor shortages, rising drug prices, provider contracts, and more.

Looking at How Medicaid Expansion Affect Sexual and Reproductive Health

June 30th, 2023|Categories: Featured, Industry News|Tags: , , , , |

Extensive research has explored how Medicaid expansion has impacted health outcomes in 40 US states, generally finding that it improves health outcomes for patients and provides financial benefits for state governments. A new report by the Kaiser Family Foundation reviews the recent literature exploring the impact of Medicaid expansion on reproductive and sexual health, beginning with coverage.

Tips for Managed Care to Approach Value-Based Care

June 29th, 2023|Categories: Featured, HEOR Feature, Industry News|Tags: , , , , |

The shift towards value-based care has the potential to benefit patients, providers, and payers alike, but it brings about unique challenges for managed care plans. In a new Managed Healthcare Executive article, learn more about value-based care payment models and strategies to apply them successfully in managed care organizations.

Study Finds Americans with Health Issues Sticking with Managed Care Plans

June 28th, 2023|Categories: Featured, Industry News|Tags: , , , , |

A recently published study in JAMA finds that sicker patients of advanced age tend to stick with managed care plans. This is a change of pace from recent years, when the industry was decried for preferentially selecting healthier patients. The study was conducted using Medicare enrollment data taken from 45,000 patients.

NICE Requests More Data Before Covering Mounjaro

June 27th, 2023|Categories: Featured, Industry News|Tags: , , , , , |

The UK’s National Institute for Health and Care Excellence (NICE) has sent a request to Eli Lilly asking for more data regarding Mounjaro (tirzepatide) before it will cover it for NHS patients. The decision comes based on data comparing the drug’s efficacy to Novo Nordisk’s rival drug Ozempic and standard insulin therapy. While the data showed Mounjaro was more effective at weight loss and glucose control, NICE needs more information before making a coverage decision.

Catching Up with the Latest from CMS

June 21st, 2023|Categories: Featured, Industry News|Tags: , , , |

The US Centers for Medicaid and Medicare Services (CMS) has been busy over the past few months. In a new Becker’s Payer Issues article, learn about the 13 latest moves by the agency that you should know. The first is a new projection by the agency, which expects to see a 7.7% increase in payer spending this year, as well as a 2.1 drop in Medicare spending.

Wells Fargo Sees Opportunities in Managed Care Stock Sell-Off

June 21st, 2023|Categories: Featured, Industry News|Tags: , , , , |

A wave of stock sell-offs in the managed care industry represent a buying opportunity, according to analysts at Wells Fargo. The sell-offs were sparked by comments from UnitedHealth and Humana that noted an uptick in procedures covered by Medicare Advantage plans that were likely postponed during the pandemic.

US Congress Wants CMS to Up Telehealth Usage While Cutting Payments

June 16th, 2023|Categories: Featured, Industry News|Tags: , , , , , |

The US Congress’s Medicare Payment Advisory Commission (MedPAC) has asked the Centers for Medicare and Medicaid Services (CMS) to ramp up telehealth utilization while, at the same time, cutting the payment rates associated with it. The request comes as the post-pandemic status of telehealth looks uncertain with policy changes following the recent end of the COVID-19 public health emergency.

Financial Pressure on Healthcare Systems Continues to Mount

June 15th, 2023|Categories: Featured, Industry News|Tags: , , , , |

With labor costs rising, decreased demand, and supply chain issues cropping up across the board, health systems faced financial difficulties in the past year. This is expected to get more pronounced over the coming years, despite consumer inflation outpacing inflation in healthcare prices. Changes in patient usage are further contributing to cost increases.

EFPIA Calls for EU Digital Health Regulatory Harmonization

June 9th, 2023|Categories: Featured, Industry News|Tags: , , , |

The European Federation of Pharmaceutical Industries and Associations (EFPIA) has released a report highlighting the need for harmonized regulatory requirements for digital health devices and apps. As it stands, only a few countries in the EU have standards for value assessment, reimbursement, and funding pathways. The EFPIA argues that this lack of harmonization constitutes a barrier to access for patients.

A Look at How Medicare Advantage Affects Providers

June 6th, 2023|Categories: Featured, Industry News|Tags: , , , , |

Although Medicare Advantage (MA) has been greatly beneficial for participating payer organizations, the picture is less rosy for providers, according to an analysis from the Kaiser Family Foundation (KFF). Providers must deal with a more complex policy framework when working with MA plans, resulting in an increased administrative burden and higher costs.

Better Employee Health Through Specialty Rx Carve-Outs

June 2nd, 2023|Categories: Featured, Industry News|Tags: , , , , |

Specialty Rx carve-outs allow for dedicated management of high-cost specialty medications by bypassing traditional pharmacy benefit managers (PBMs). Doing so, according to a new article in Corporate Wellness Magazine, can help improve employee health by applying specialized expertise to coverage decisions, better coordinating care management, and reducing costs.

Over 500,000 Disenrolled from Medicaid After COVID-19 PHE Ends

June 1st, 2023|Categories: Featured, HEOR Feature, Industry News|Tags: , , , |

Shortly following the end of the COVID-19 public health emergency, pandemic-era restrictions on Medicaid redetermination ended. In that time, over 500,000 people have been disenrolled, interrupting their coverage and impacting their access to healthcare. Some states have kicked off more beneficiaries than others, with Florida taking the lead.

Incorporating Value-Based Care into Nursing Homes with the Payvider Model

May 31st, 2023|Categories: Featured, Industry News|Tags: , , , |

As nursing homes increasingly look for ways to incorporate value-based care into their practices, some are moving towards payvider models, wherein they partner with a Medicare Advantage insurer and play the roles of payer and provider together. A panel of experts spoke about this strategy in a recently broadcast webinar by NetSmart Technologies.

Speaking with the Person Behind the Inflation Reduction Act Drug Price Negotiations

May 30th, 2023|Categories: Featured, Industry News|Tags: , , , , |

The US drug pricing reform in the Inflation Reduction Act was concocted by John Barkett of the Berkely Research Group. In a new interview, Politico’s Ben Leonard spoke to Barkett to talk about the process and the next steps for the Centers for Medicare and Medicaid Services (CMS). Barkett first spoke about pharma’s criticism of the move and the agency.

Expiration of Temporary Provisions Set to Change Up Insurance Coverage for People Under 65

May 30th, 2023|Categories: Featured, Industry News|Tags: , , , |

COVID-era policies expanded access to Medicaid and Marketplace plans for millions of people in the US, resulting in the lowest rates of uninsured status ever. However, these policies are set to expire soon, resulting in many people under 65 losing their coverage. In a new Health Affairs article, learn more about the state of insurance coverage of people under 65 years of age and how it’s set to change in the coming decade.

Part D Out-of-Pocket Prescription Drug Price Cap Will Help New Part D Recipients

May 30th, 2023|Categories: Featured, HEOR Feature, Industry News|Tags: , , , |

A newly published study in JAMA Health Forum found that new Medicare Part D price caps on out-of-pocket prescription drug costs will help new beneficiaries switching from commercial plans. The study found that the $2000 price cap in the provision, included in the Inflation Reduction Act, would save people switching from commercial plans to Part D.

Talking 340B with Sara Hearn of RxBenefits

May 19th, 2023|Categories: Featured, Industry News|Tags: , , , , |

The US 340B program requires drugmakers to provide certain medications at a significant discount to safety-net care centers that provide care for patients in economically disadvantaged areas through Medicaid and Medicare Part B. In a new BenefitsPRO interview with Sarah Hearn of RxBenefits, learn how the 340B program has impacted manufacturers and commercial payers.

Federal Appeals Court Keeps ACA Preventative Care Rules in Place

May 16th, 2023|Categories: Featured, HEOR Feature, Industry News|Tags: , , |

A US Federal appeals court has issued a stay on a lower court’s ruling that would gut the preventative care requirements in the Affordable Care Act. If not paused, the lower court’s ruling would end the requirements for payers to cover preventative care services like physicals, Pap tests, cancer screenings, and pre-exposure prophylaxis (PrEP) for HIV.

Promoting Health Equity and Community Health with Medicaid Reinvestment Requirements

May 11th, 2023|Categories: Featured, Industry News|Tags: , , , , |

Several states have adopted policies that make Medicaid managed care plans put money back into local communities to promote health equity and community health by targeting social determinants of health (SDoH) associated with poor health outcomes. In a new Health Affairs Forefront article, learn about the challenges blocking the full realization of these policies’ potential and best practices in developing them.

New Proposed CMS Medicaid and CHIP Managed Care Rule Targets Access, Quality, and Payment Rates

May 11th, 2023|Categories: Featured, Industry News|Tags: , , , , |

A newly released proposed rule by the US Centers for Medicare and Medicaid Services (CMS) targets transparency, quality, care access, and payment rates for Medicaid and Children’s Health Insurance Program (CHIP) managed care. States would need to provide an annual payment analysis of all managed cares payment rates for a variety of services. In addition, states will need to develop a quality rating system for Medicaid and CHIP plans.

Go to Top