In my experience, I’ve found that C-level executives often have a difficult time grasping the concept of cost avoidance in the healthcare industry. Most people view cost avoidance in the context of prioritizing investment decisions in a world of constrained
Don’t Fall for Fancy Buzzwords: Risk Stratification is Not the Same as Predictive Modeling
From day-to-day, I meet many C-level executives from a range of healthcare organizations – Medicare and Medicaid HMOs, ACOs, IDNs, large hospital networks, provider groups and other healthcare organizations that are taking on risk contracts. We often discuss the latest
Why High Quality Scores Don’t Always Translate to PMPM Reduction
One of the biggest frustrations for executives at health plans and providers participating in risk contracts or value-based contracts is the realization that high quality scores do not always translate to better outcomes or lower per-member-per-month costs. I have had
Optimization: Fee-for-Service Versus Pay-for-Performance Versus Full Capitation
The healthcare industry is constantly evolving and changing. Today, there is a lot of change in the way organizations care for their populations and the care delivery models. New care models incentivize keeping populations healthy through better preventative care, proactive
Looking at Population Health from “A Healthcare Resource Optimization” Perspective
The goal for any population health program should be to keep members healthy and prevent the onset and advancement of disease. Historically, population health programs have been disjointed because payers, providers, employers and communities execute isolated efforts with no collaboration
Does MACRA Mean the End of Fee-For-Services?
When the calendar flipped to 2017, it heralded a year that will be radically different from the one it preceded. One industry that will certainly experience some upheaval is healthcare. In fact, those changes began day one as the MACRA
Is the Repeal of Obamacare Good for America?
January 20, 2017, the day of Donald Trump’s inauguration marked a new era for the healthcare industry, one that’s filled with uncertainty and confusion. In other words: more of the same. One of Trump’s first acts after he was sworn
Predictive Analytics Delivers a Solution for Providers Overburdened by Mental Health Issues
On December 13, President Barack Obama signed into law a broad and sweeping healthcare provision known as the 21st Century Cures Act. In these contentious political times, the law is being heralded as a rare show of bipartisanism after it passed
Partnerships between Payers & Providers will Ease the Transition to Value-Based Care
The healthcare industry is successfully transitioning to value-based care, even while the fate of the Affordable Care Act (ACA) remains unclear. This is according to a recent McKesson study that shows both payers and providers making profits from value-based care.
Health Analytics: Better Outcomes Mean Better Success, No Matter What Happens to the ACA
Things were looking down for the Affordable Care Act (ACA) even before Donald Trump won the election. Premiums for several health plans are increasing by an average of 25 percent next year. Consumers in many states have significantly fewer insurance
From Obamacare to Trumpcare: The Future of the ACA Under President-elect Trump
On November 8, 2016, the American people made an historic choice and elected the ultimate outsider as president of the United States: Donald Trump. President-elect Trump will likely put forth many policies that differ from the Obama administration. This includes
This Shocking Healthcare Expense Costs the Industry Billions, But it Can Be Prevented
Despite the recent passage of the Affordable Care Act, healthcare costs continue to skyrocket. Many factors contribute to this cost increase, including: Pharmaceuticals Medical inflation Specific diseases and conditions like heart disease and cancer However, the most expensive healthcare cost
Healthcare Analytics: Powerful Results Are Possible, Organizational Buy-In Is Required
As is widely reported in the news, the healthcare industry is in the middle of a massive transformation. Due in large part to the Affordable Care Act (ACA), the industry is shifting from traditional fee-based care (where providers are compensated
ACOs Need to Fully Embrace The Shift To Value-Based Care To Succeed With The ACA
Participants are fleeing the Affordable Care Act (ACA) in droves citing high costs and difficulties achieving benchmarks. Aetna recently pulled out from 11 states. UnitedHealth narrowed its offering to only a few states. And many smaller carriers, like the struggling start-up Oscar
How Healthcare Analytics is Fulfilling The Promise To Revolutionize Healthcare
Healthcare professionals and the general public view healthcare analytics with optimistic skepticism. As the following examples illustrate, it’s time for healthcare analytics vendors to show results. Recently, NPR examined some highs and lows of healthcare analytics to determine the effectiveness
Dirty Healthcare Data? One Healthcare IT Vendor Provides True Value By Cleaning It
Speaking at the Office of the National Coordinator for Health Information Technology’s (ONC) annual meeting in Washington, Karen DeSalvo, the national coordinator for health IT, addressed what she believes to be the critical challenges for the healthcare industry: data interoperability
CMS Star Ratings – Here’s the Bottom-Line on How to Improve and Maintain Them
Star Ratings are increasing the pressure on health plans and directly affecting their bottom line.In 2012, the Centers for Medicare and Medicaid Services (CMS) began measuring Medicare Advantage and Part D prescription drug plans using the Star Ratings, a five-star system
Payers are Hemorrhaging Money – Can Predictive Analytics Stop the Bleeding?
Oscar Health Insurance burst on the payer market in July 2013 and by April 2015 the company was valued at 1.5 billion dollars. However, in March of this year, Oscar revealed it lost over 100 million dollars last year.While the news
What Quality Measures Get Wrong – and How to Make Them Right
Healthcare is continuing its, somewhat painful, evolution from volume-based to value-based care. As it does, government programs, like Medicare, and private insurance companies increasingly use “quality measures” to evaluate a physician’s performance level. However, since everyone seems to have a