Blog

The State of California is “carving out” the pharmacy benefit for Medi-Cal beneficiaries from managed-care plans and transitioning to a fee-for-service (FFS) program, moving 13 million Medi-Cal beneficiaries to a new pharmacy program by January 2021. Medi-Cal is taking responsibility from the managed care organizations (MCOs) for one of the key elements of care, the […]

The Affordable Care Act (ACA) has survived for a decade despite Congressional attempts to repeal it, executive orders to weaken it, and some Democratic Presidential candidates proposing to upend it in favor of a single-payer system. Despite the political rhetoric and executive actions, participating ACA individual insurers experienced a highly profitable 2019. This resulted in […]

The expiration of the Texas 1115 Waiver at the end of September 2022 is a call to action. With the uncertainty surrounding the Texas 1115 Medicaid Waiver renewal, the state’s Health and Human Services Commission may consider some of the policy and regulatory changes to the Medicaid program that the Centers for Medicare and Medicaid […]

In the calendar year (CY) 2020 for the “Value-based insurance design” (VBID) Model and has expanded opportunities for CY 2021 including a new hospice benefit. The VBID Model aims to increase health care quality and decrease costs for Medicare Advantage (MA) by leveraging financial incentives to promote cost efficient health care services and expand consumer […]

The new decade has barely begun, but already 2020 is shaping up to be another pivotal year in health care. With all the innovation taking place in payment models, service delivery, technology and other areas, it is easy to lose sight of the fundamental drivers of the emerging health care industry. This article outlines four […]

Academic Medical Centers (AMCs), for the large part, are late to the population health game and have been playing catch-up. Though uniquely innovative and focused on both clinical care and research, AMCs are challenged by systemic obstacles that make transformations difficult as change requires new levels of collaboration across the entire organization. Simply put, changing […]

Independent Physician/Provider Associations (IPAs) are key mechanisms for physicians, health systems and federally qualified health centers (FQHCs) to align and engage in value-based payment arrangements that add value to payors and attributed members. This paper provides insights into the benefits to IPAs for engaging FQHCs and community-based organizations (CBOs) into their network, care model and […]

Analytics for Risk Contracting (ARC) helps organizations manage and succeed in risk-bearing payment arrangements such as Medicare Direct Contracting (MDC). The ARC platform can help prospective Medicare Direct Contracting applicants address key business decisions related to MDC-specific requirements and operational parameters required to become a Direct Contracting Entity (DCE). Medicare Direct Contracting applicants can leverage […]

The New York State Department of Health (NYSDOH) recently released a draft proposal to extend 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 the Centers for Medicaid and Medicare Services (CMS) for $8 billion over four […]

Medicare Direct Contracting (MDC) is a unique opportunity for providers and payors to align financial incentives and redesign care for Medicare fee-for-service beneficiaries. To succeed under this model, risk bearing organizations need to be able to reduce total cost of care and improve performance against key quality metrics. To maximize success in Medicare Direct Contracting […]