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California is staking out bold new requirements for commercial health plans interested in providing managed care services for Medi-Cal, the state’s Medicaid health insurance program for low-income children, adults and seniors. Up for grabs are contracts to provide Medi-Cal coverage in 33 of 58 California counties and for 38% of the state’s Medicaid population. Roughly […]

Despite pressure from some advocates to drop the Medicare Direct Contracting program, the Centers for Medicare and Medicaid Services’ (CMS) Centers for Medicare and Medicare Innovation (CMMI) has updated MDC into an accountable care organization program with an increased focus on health equity. It’s a win-win for providers looking to access value-based care and payments. […]

It’s increasingly clear that the public health crisis created by COVID-19 has exacerbated long-term, structural challenges in the U.S. health system. This is particularly true for how health care is delivered and clinicians, especially physicians, are paid. The pandemic has also highlighted the wisdom of seizing opportunities for innovation and reinvention, as well as the […]

Benchmarking adds an important dimension to measuring and propelling performance and market competitiveness. It enables providers and payers to understand how they stack up against industry leaders and local players on key performance indicators as well as national standards of excellence. The first step in a successful benchmarking process is to establish a baseline of […]

Challenge: Frequent regulatory and plan requirement changes, coupled with the need to adapt to pandemic challenges, prompted Uniformed Services Family Health Plan to find a partner to undertake a thorough review and restructuring of its medical management program. US Family Health Plan, a TRICARE Prime® military health care option serving military families in New […]

There can be significant conflict when it comes to designing and implementing a utilization management (UM) program. UM is designed to ensure care is aligned with nationally recognized clinical standards and to minimize cost related to unnecessary care. It’s a primary cost-control strategy for commercial and government payers as well as some independent physician associations […]

Fragmented, uncoordinated care remains a bane of the U.S. health care system. Certainly, health systems, hospitals, and medical organizations have made strides in offering ancillary care support, such as social workers to help patients, primarily after treatment. However, the current model depends on care management infrastructure and services that work around providers, rather than integrating […]

If you’ve invested in population health staffing, resources and services but are still struggling to lower costs and improve care, you should look at your physician compensation models. The failure to appropriately compensate primary care physicians for managing populations and total cost of care remains a major obstacle to transforming care delivery, costs, and revenues. […]

When health leaders are scrambling to ensure adequate staffing every single day, bringing a more strategic focus to their healthcare workforce may not make it to the top of the to-do list. But a long-term holistic approach that begins quickly paying off is exactly what’s needed to move away from the constant staffing fire drills […]

Health equity is at the top of the agenda for growing numbers of providers as well as the Biden Administration: 58% of health systems now say health equity is a top priority, up from 25% in 2019, according to the Institute for Healthcare Improvement. A key to erasing racial and ethnic healthcare disparities including access […]