Blog
Insurers Increase Participation in ACA Markets and Must Focus on Key Provider Partnerships
October 30, 2019The Affordable Care law has survived for nearly a decade despite efforts to upend it, including legal challenges (one pending1 and another that went all the way to the Supreme Court), Congressional attempts to repeal it and executive orders aimed at weakening it. While fiery debate continues over the fate of the roughly 21 million […]
Building a Medicare Advantage Network
October 30, 2019Background The Health Plan is a not-for-profit health plan in the Northeast that services more than 280,000 members, offering Medicaid, Medicare and Children’s Health Insurance Program (CHIP) plans. The plan has consistently ranked high on the National Committee for Quality Assurance’s (NCQA) quality metrics but had a relatively small footprint in its target markets, despite […]
Redesigning the Model of Care during the Procurement Cycle
September 26, 2019Background: A large public health plan in the Northeast was in the midst of the procurement cycle for a state demonstration. The product proposed for the demonstration covered under 65 dual-eligible members, a high-risk population, in which there was a large proportion of chronic conditions and mental health and substance use disorder (MH/SUD) comorbidities. […]
Integrated Acuity-based Care Model Design and Implementation for Vulnerable Populations
September 26, 2019Overview: As today’s vulnerable populations present with more complexities, designing care models and identifying the appropriate multidisciplinary resource mix is key to delivering integrated, member-centered, outcomes-based care. As the health care industry continues to recognize the need for holistic care that meets the objectives of the Quadruple aim while addressing the social determinants of […]
New York State DSRIP Extension Summary Notes
September 21, 2019Key terms of the proposed extension: 4-year extension Continuation of DSRIP for 1 year 3-year renewal Would span from April 1, 2020 through March 31, 2024 $8B in funding $5B for DSRIP Performance $1B for Workforce Development $1.5B for Social Determinants of Health $0.5B for Interim Access Assurance Fund New structure for organizations participating […]
New York’s Proposed DSRIP Extension: What does it mean for Performing Provider Systems and Risk-Bearing Entities?
September 20, 2019The State of New York has released its draft proposal for an extension to its Delivery System Reform Incentive Payment (DSRIP) program as part of the state’s 1115 Medicaid waiver, currently set to expire at the end of March 2020. Asking CMS for $8 billion over four years to extend the program through March 2024, […]
Developing and Executing on a Competitive Procurement Strategy
August 27, 2019Background Managed care procurement processes are a required part of public sector care delivery as value-based care continues to advance in the health care industry. As a bidder, one often associates the process with a heavy amount of administrative effort, resource consumption and bureaucratic requirements. While there is truth to this, well-conducted procurement processes can […]
Designing Effective Organizational Care Management to Gain Control of the Total Cost of Care
August 27, 2019Background A risk bearing entity’s (RBE) ability to bear financial risk profitably is based on its ability to consistently manage the utilization and health outcomes of its attributed population. In today’s market, to be a RBE is to be in the business of care management. Successful care management is a critical competency that organizations must […]
Payer-Provider Partnerships are the Cornerstone of Improving Health Plan Quality Scores
August 27, 2019Payers of all stripes are increasingly holding health plans accountable for moving the health care system from the horse and buggy era to a “transportation network” for entire populations. The Centers for Medicare and Medicaid (CMS), state government and employers have heightened expectations for health plans to do more to achieve specific and complex quality […]
Leveraging Pharmacy Data to Improve Total Cost of Care
July 11, 2019Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced a new payment model for the catastrophic phase of the Part D Medicare benefit. Under this new model, CMS aims to reduce total spend on prescription drugs by incentivizing health plans, patients, pharmacy benefit managers (PBMs) and providers to choose drugs with lower […]