How is it that well-informed people can look at the same data and come up with dramatically different conclusions and action implications? It turns on whether the analysis is done by biostatisticians looking at utilization data in an academically rigorous way, or by actuaries and benefits consultants looking at overall financial trends in a pre-post manner.

Sometimes in our technology-driven environment, we get into a fixed routine of the current standard of care for our patients. What would we see or hear if we saw our practice or facility through the eyes and ears of our patients?

Healthcare will never be an industry where one size fits all, but through reducing adminstrative complexity, resources can be redirected and put to better use.

Regardless of the structural framework of any nation's healthcare system, a critical measure of its success will depend upon the aligned incentives and objectives of its key constituents.

Disease management—or, what we have known as disease management—stands at a crossroads, as changing demands in the marketplace and a growing emphasis on wellness and prevention recast our thinking on chronic care. Can DM survive?

Probably never before in the history of managed care have health plans tolerated a bigger gap between actual and potential reimbursement than in Hierarchical Condition Coding (HCC) for Medicare Advantage (MA).

While your pharmacy benefit program has no doubt been managing utilization for years with core strategies, it's important to review effectiveness often. Below are the proven strategies that payers should analyze frequently in the current market of increasing utilization.

The mother of a child suffering from asthma calls Medical Mutual of Ohio's Nurse Line desperately needing advice. The nurse listens to the mother's concern and is poised to tell her everything she needs to know, but instead, the mother is told that she is not covered for this particular service.

Today, healthcare payers and providers endlessly wrestle with three alligators—rising costs, inconsistent quality, and the uninsured. These alligators seem to grow larger and stronger with every passing year.