Joseph Burns

Iowa's Department of Health and Human Services, which manages the two health insurers that delivered care to adults and children in the state’s Medicaid program last year, was alleged to provide inadequate mental and behavioral health care to children on Medicaid.

Since 2017, two lawsuits and two state audits have cast a harsh light on Medicaid managed care, which served 845,000 adults and children at a cost of almost $6 billion last year.

Millions of people may lose coverage when continuous enrollment ends in May. But tens of thousands may be added back, thanks to a federal judge’s ruling.

This portion of the month's cover story series spotlights PBM EmsanaRx, a branch of Purchaser Business Group on Health (PBGH), and its President and CEO, Elizabeth Mitchell, who explains that EmsanaRx differs from other PBMs because they use what PBGH calls a waste-free formulary. This months cover story shines a light on the companies, trends and ideas that are shaking things up and reshaping the contour of how healthcare is paid for and delivered.

Take a look into this month's cover story series of the companies, trends and ideas that are shaking things up and reshaping the contour of how healthcare is paid for and delivered. Below spotlights Alexander Oshmyansky, M.D., Ph.D, and his company he founded, Cost Plus Drug, also known as Mark Cuban Cost Plus Drug Company.

Employee benefit consultants who advise employers on the most cost-effective options for companies contracting with health insurers have seen both the advantages and disadvantages of alternative health plans.

When representatives of alternative health plans pitch employers, they promote the idea that these plans allow members to choose high-quality physicians and hospitals that keep costs low.

By cutting costs for employers and reducing or eliminating out-of-pocket costs for employees, alternative health plans are taking market share from traditional insurance. The plans say they can cut costs by steering members to high-value providers.

Most states have contracted with insurers to manage their Medicaid programs. Connecticut uses administrative services only contracts and a variety of means to manage the care.

Experts say Democrats and Republicans could work together on telehealth, mental health and physician payment issues in 2023.

North Carolina pioneered patient-centered medical homes and other ways of managing the healthcare of Medicaid beneficiaries. But it was one of the last states to contract with managed care organizations and hasn’t expanded Medicaid.

The program started before specialty drugs became such a large expense for Medicare and its beneficiaries. Congress is considering legislation that would cap beneficiary out-of-pocket costs and require price discounts from manufacturers.

As many asme 14 million people with Medicaid coverage stand to lose their health insurance when the COVID-19 public health emergency ends.

States looked to Medicaid managed care plans to control costs and provide some predictability. Now a growing number are asking questions of the plans and investigating whether the plans are living up to their state contracts. Meanwhile, new federal reporting requirements are being implemented that may shed some light on how the plans operate.

Price-transparency rule allows insurers to cut MLR payments by using incentives to encourage consumers to choose low-cost, high-value providers.

Although health systems say they deliver better health outcomes and lower costs, research on how physicians are compensated suggest otherwise.

The proposed rules might ratchet down drug costs for Medicare beneficiaries and would set network adequacy standards.

Coverage requirements may result in premium hikes next year, say some health plan executives.

In the sixth year of Medicare’s Independence at Home Demonstration program, the initiative saved $41 per member per month, an amount that CMS says was not statistically significant and was lower than the savings the program produced in earlier years.

The Community Aging in Place—Advancing Better Living for Elders (CAPABLE) program developed at the university’s nursing school is designed to keep older people who are frail, have chronic medical conditions or can’t complete activities of daily living in their homes by providing care and help from conventional healthcare professionals — nurses, occupational therapists — but also from people who can do minor house repairs.

Keeping older people in their homes has cost and care advantages. Yet Medicare and Medicaid are still geared toward paying for care in institutionalized settings.

For many people, telehealth is an inviting option. But some insurers are offering health plans that make it the main way by which people receive primary care.

Cost pressures may increase as the Medicare Hospital Insurance Trust Fund runs low, but the reliance on telehealth that the pandemic wrought is likely to continue, especially for mental health services.

At the state and local levels, an increasing number of markets are dominated by one or a handful of insurers. Experts say it is part of a vicious cycle of payers responding to provider consolidation and vice versa.

Medicare funding shortfalls may trickle down to the Medicare Advantage plans and the Star Rating program bonuses, which have quadrupled in recent years.

The number of participants in the Medicare Shared Savings Program has tapered off, and the Direct Contracting Model may put accountable care organizations at a disadvantage. The National Association of ACOs wants the Biden CMS to make some changes.

Companies could be hit with a double peak of claims for COVID-19 patients and care that people put off because of the pandemic.

For several years, the Association of American Medical Colleges (AAMC) has presented data showing that the United States faces a shortage of physicians in almost every specialty. In June 2020, the association issued its sixth annual report on the shortage, predicting that in just over a decade, the U.S. healthcare system would face a shortage of between 54,100 and 139,000 physicians in primary and specialty care.

A favorable Supreme Court ruling has improved the financial outlook of the three nonprofit health insurers.

Here's what healthcare executives can expect depending who wins next week's election.