Blog

If you’re in a convener-led ACO and think downside risk isn’t your problem, that may be about to change. CMMI is signaling a move toward requiring providers themselves to assume part of the financial risk even if they are participating in an ACO through a convener. This shift would dramatically reshape long-standing assumptions about Medicare […]

As healthcare organizations navigate a rapidly evolving landscape shaped by value-based care, population health, and payer-provider realignment, many providers are turning to Management Services Organizations (MSOs) to enhance operational efficiency and fuel growth. Whether you’re an independent practice, a medical group, or an emerging provider network, evaluating the size and scope of your MSO is […]

Medi-Cal Transformation is evolving and the lessons learned since its launch in 2022 have created significant discussion throughout California and other states regarding opportunities to leverage lessons learned in California for Medicaid redesign and in other states for their own Medicaid transformation and waiver efforts. Medi-Cal transformation, formerly known as California Advancing and Innovating Medi-Cal […]

What Happened?: In early July, CMS announced that they will be launching a new technology focused prior authorization process in six states to help combat fraud, waste and abuse in Traditional Medicare. CMS has highlighted that fraudulent or abusive billing practices, the provision of services with minimal clinical benefit and the use of riskier […]

With reductions in healthcare funding on the horizon, especially in Medicaid, proactive planning is essential to optimize the use of limited care dollars. Reengineering care delivery and transforming practices are not optional but necessary steps to safeguard care access and quality under tightening budget conditions. Data analytics will provide a critical foundation for informed decision-making, […]

California’s Medi-Cal program is facing a period of fiscal tightening that we have not seen since the enactment of the Affordable Care Act back in 2010. Driven by both state-level budget constraints and federal policy proposals, cuts will be real and painful. With the Medi-Cal program’s costs projected to exceed $194 billion by FY 2025-26, […]

The Center for Medicare and Medicaid Services (CMS) recently issued a notice announcing changes to the ACO REACH for Performance Year 2026. The ACO REACH currently is projected to conclude at the end of 2026, but there is ongoing speculation around a potential expansion. CMS’ intent of these changes is to improve model sustainability by […]

Federally Qualified Health Centers (FQHCs) play a critical and innovative role in delivering comprehensive care to underserved communities, yet they face ongoing challenges in sustaining financial health and operational efficiency. With Medicaid and Medicare margins tightening as rate increases lag behind inflation, and expected reductions in Medicaid and ACA marketplace membership to cause a growth […]

Justice-involved individuals (JIIs) reentering society often face a complex mix of challenges: Chronic health conditions, mental health and substance use disorders, unstable housing, limited job prospects, and a deep distrust of systems. The first 90 days after release are critical. Without solid, coordinated care, many fall through the cracks increasing the likelihood of adverse health […]

California’s healthcare landscape is undergoing a significant transformation with the integration of Community-Based Care Management into Dual Eligible Special Needs Plans (D-SNP) under the CalAIM initiative. The shift aims to enhance care coordination for individuals eligible for both Medicare and Medi-Cal, aligning with the principles of Value-Based Care (VBC).   What is CICM?: California […]