State of the Industry 2013: Payer Profitability

Even though the Inflation Reduction Act will require plans to justify formulary placement of negotiated drugs, payers have more of an incentive to steer patients to lower-cost alternatives.

Risk adjustment is a central feature of value-based care, but it can be abused. Natural language processing can make the process efficient and steer it clear of fraud and other problems.

The trend of primary care practices and businesses bearing risk has pitfalls. A trio of experts have suggestions for how they can be avoided, including taking steps to de-emphasizing diagnostic coding in the calculations that determine payment.

The plaintiffs in Kelley v. Becerra are arguing that the Affordable Care Act’s requirement that preventive services be covered without cost sharing is unconstitutional. In a factsheet published yesterday, the Urban Institute says that the ACA requirement has had an especially a large effect on women, partly because contraception is among the services covered by the no-cost-sharing rules that apply to private insurers.

Medicaid managed care organization (MCOs) may be better equipped to address social determinants of health (SDOH) and health equity than payers who use fee-for-service models because SDOH are central to many requirements for MCOs, including those pertaining to population health management, health equity and care coordination.

During the state of the industry webinar, AHIP experts reviewed policies and solutions to improve affordable access to care and shape healthcare in the post-pandemic world.