Industry Analysis

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.

François de Brantes, a member of the Managed Healthcare Executive ® editorial advisory board and senior partner at High Value Care Incentives Advisory Group LLC, describes what he believes has caused a major inflection point in the management, delivery and payment of U.S. healthcare

Researchers examined data from the 2019 and 2021 American Community Survey and found that, nationally, the uninsured rate declined from 11.1% to 10.5%, a change that represents more than 1.6 million people gaining coverage.

After some go-go years, Bright Health, Oscar and Clover Health are leaving some markets.

The nine models geared toward acute and specialty care produced better results than the 12 that focused on primary care and population health.

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

Andrew Shadid and Genesis Orthopedics & Sports Medicine applied some of the principles of reverse innovation to make the practice successful.

More practices are directly dispensing oral cancer drugs, bypassing specialty pharmacies. What does this trend mean for patients and healthcare?

As SCAN Health Plan worked to boost medication adherence among members, it made a startling discovery.

“For the past 20 to 25 years, the data has fairly consistently shown that, overall, of people who have been prescribed long-term medications, about half of those patients are not going to take them as prescribed,” says Todd Ruppar, Ph.D., a professor in the College of Nursing at Rush University in Chicago.

Its physicians are overworked, and patients are going elsewhere for care. Experts say help is on its way for primary care in the United States — but so is an onslaught of new demands.

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.

Various groups, clinics and organizations have set up places for people without housing to recover from an injury, surgery and serious illness.

Kaiser Family Foundation research shows that an 8% increase in enrollment from 2021 to 2022.

Drug manufacturers are rejecting the program’s blanket discounts involving contract pharmacies. A flurry of litigation has ensued.

Private equity firms have pulled back some this year, but money has been pouring into the healthcare sector. Will the cash infusion make healthcare more efficient or drive up costs as investors seek returns?

Pharma, health insurers square off about the healthcare provisions in the Inflation Reduction Act that passed the Senate yesterday. The PhRMA was sharply critical of the provisions that would empower CMS to negotiate the prices of a selected number of drugs. AHIP praised the extension of more generous ACA premium subsidies.

Automation not only eases the financial pressure these organizations are often under but requires less manpower, which helps overcome challenges associated with worker shortages, all while supporting a positive vendor relationship.

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.

Some experts want to see more funding for hospice care in the home. Others say the advantages of hospice in a hospital or nursing home have been underrated.

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

Beauty may be in the eye of the beholder, but drug price trends are in the way you crunch the numbers.

As personalized medicine grows, so does the need for specialized management of laboratory testing.

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

Patients are likely to continue to choose to recover at home rather than go to skilled nursing facilities, according to a new report by Trella Health.

Equity is a central part of healthcare quality, but health plans often lack information on individual members’ race and ethnicity, making assessing and improving health outcomes challenging.

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

Like the entirety of the world, the COVID-19 pandemic exposed many issues in the medical industry. One area in particular: the clinical trials space developed many challenges as a result to the height and continuous battle of the pandemic.