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Background 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 […]

Payers 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 […]

Earlier 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 […]

The Centers for Medicare and Medicaid Services (CMS) announced in April its new direct contracting model that will push the Medicare market closer to commercial and will resemble Medicare Advantage without a health plan as an intermediary. With a focus particularly on primary care coordination for medically complex and seriously ill patients, as well as […]

Effective July 1, 2019, the California Department of Managed Health Care (“Department” or “DMHC”) is requiring organizations under certain conditions to file their risk contracts with DMHC.1 California managed care organizations, medical groups, risk bearing organizations (RBOs), clinically integrated networks (CINs) and any entities looking to enter into upside or downside financial risk agreements will […]

Public hospitals and health systems have a commitment to provide access to care for the most vulnerable populations, including the uninsured and underinsured. They also have a unique opportunity to become leaders of a network of choice for the care of Medicaid, Medicare Advantage, dual-eligible, subsidized exchange, and other populations by overcoming the traditional siloes […]

Background Starting in 2011, the Center of Medicare and Medicaid Services (CMS) has required health care systems to deliver the Important Message from Medicare (IM) to all Medicare beneficiaries who are hospital inpatients. This admission notice provides beneficiaries and representatives a written notice about their hospital discharge appeal rights. CMS regulation dictates that IM delivery […]

Background Starting in 2011, the Center of Medicare and Medicaid Services (CMS) has required health care systems to deliver the Important Message from Medicare (IM) to all Medicare beneficiaries who are hospital inpatients. This admission notice provides beneficiaries and representatives a written notice about their hospital discharge appeal rights. CMS regulation dictates that IM delivery […]

Thank you all for joining our Las Vegas Population Health 360 Conference. More than 100 health care leaders gathered for this invite-only event to discuss current trends, challenges and the future vision of the value-based payment landscape. Attendees engaged in a series of panels and round table discussions throughout the two days to learn best […]

Background In 2013, the Texas Legislature created The University of Texas Rio Grande Valley (UTRGV) to increase educational opportunities in the surrounding Rio Grande Valley area, located at the state’s southernmost point along the Mexican border.1 The Rio Grande Valley has an estimated population of about 1.5 million residents.2 In conjunction with the school’s founding, […]