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Prices, not utilization, drive highest healthcare spending


What's driving the highest per capita healthcare spending in the country? A half-decade's worth of government-funded research points to some contentious and perhaps uncomfortable trends. Read more »

Docs fight to protect self-referrals


Physicians groups want to preserve a key antitrust exemption for self-referrals under Medicare that the Obama Administration hopes to end for a number of costly services. Read more »

Public exchange formulary controls present a 'new frontier'


Health insurers can expect an increasing number of consumer education challenges around prescription drug management, as utilization controls are more prevalent in public exchange plans than in typical group insurance. Read more »

WellPoint projections buoyed by exchange enrollment


With open enrollment coming to a close, public insurance exchanges are starting to look like they won't be the money-loser many have been girding for, at least for WellPoint's health plans. Read more »

Troubled exchanges seek more time


Amid problems ranging from the minor to the extreme, at least half a dozen state exchanges are offering enrollment extensions of sorts, but only one is pushing federal limits and trying to extend open enrollment. Read more »

The wrong way to convert ICD-10 codes


ICD-10Grab a photograph. Any photo. Then take it to a photocopier, and copy it.  Read more »

ER study undercuts conventional wisdom on health reform


A central hypothesis underlying the case for health reform's insurance expansion is being challenged by new evidence, as the quest to reduce emergency visits and spending continues. The research also highlights ongoing concerns about primary care access. Read more »

Dual eligible managed care plans confront challenges


The largest national dual eligible demonstration project is taking a belated start in California, amid concerns from patient advocates. The concern surrounding the project indicates that new managed care plans have a long way to go, both in fixing problems in the system and getting buy-in from beneficiaries. Read more »

MedPAC takes aim at outpatient billing trend


As Congress tries to reform Medicare, the program's independent advisor has its own suggestions, including a call to end to what has become a revenue buffer for many hospitals and an integral part of their physician acquisition strategies. Read more »

Oregon tries to make Medicaid capitation work


As Oregon transforms how it delivers care to 780,000 Medicaid patients, it hopes to generate better outcomes at lower costs. The problem is these goals conflict with hospital's traditional reliance on revenue from ER visits and inpatient stays. Read more »

CMS eyes plan ratings, intervenes in drug, network access


Federal regulators are starting to finalize simmering ideas for public exchanges and also responding to consumer concerns, outlining a new quality rating system and proposals covering everything from narrow networks to loss ratios. Read more »

Hospitals face transparency pressure


The days of cryptic invoicing are coming to an end for healthcare, or at it least they should be, financial experts say. Read more »

Medicaid Commission confronts eligibility concerns, premiums and transparency


The Medicaid and CHIP Payment and Access Commission is out with its biannual report, proposing a number of changes to eligibility, premiums and disclosure policies, including some intertwining with exchange health plans. Read more »

House passes SGR repeal with a big catch


Several months of sustained legislative progress on physician payment reform has been stopped in its tracks by an add-on. Read more »

Blues company hit with 'historic' fine


As Montana's Blue Cross company evolves under a new corporate parent, state regulators are penalizing it for some alleged past misdeeds uncovered by an audit. Read more »

Anthem boasts high participation in value-based primary care


Anthem Blue Cross and Blue Shield in Colorado has convinced one-third of the state's primary care providers to join its value-based payment program, part of a wave of alternative reimbursements WellPoint is trying to spread across the country. Read more »

Startup's IPO shows booming of healthcare transparency biz


With a banner of its logo draped over the New York Stock Exchange on the Friday before St. Patrick's Day, Castlight Health went public, in another sign that reducing friction and opacity in healthcare is sparking a gold rush of sorts. Read more »

High stakes for out-of-network containment in ERISA lawsuit


Depending on the outcome of a lawsuit Cigna is pursuing in Los Angeles, more out-of-network providers may be able to offer patients discounts while billing health plans in full. Read more »

Eligibility 'churn' presents problems for states, health plans


With researchers expecting a lot of fluctuating eligibility between Medicaid and exchange subsidies among lower-income consumers, states and insurers will have to devise new ways to solve the problem of continuity of care disruptions. Read more »

Non-compliant formularies sneak past regulators, raise value questions


The drug formularies of some small group health plans in two states don't meet essential health benefit benchmarks, a new study has found, leaving researchers pointing to a solution that may be as complex as benefit mandates. Read more »

Medicaid MCOs lag in fraud prevention


Federal healthcare auditors think Medicaid managed care organizations aren't doing enough to combat fraud and that states might have to step in with policy changes. Read more »

Health insurance exchanges gaining last-minute momentum


Through the beginning of March, 4.2 million Americans signed up for private coverage through state and federally-run exchanges, leaving federal health officials hoping for a final month's surge to meet initial projections, especially for millennials. Read more »

Aetna's latest ACO aims for shared savings


Aetna is going forward with an accountable care agreement for some 28,000 people, partnering with a health system that also has accountable care contracts with some competitors. Read more »

Amerigroup first Medicaid plan to use chip-based member record


WellPoint's Amerigroup is the first Medicaid plan in the nation to use a health record chip that enthusiasts are calling a "breakthrough health IT solution." Read more »

NCQA to overhaul health plan accreditation


The National Committee for Quality Assurance wants to modernize its health plan accreditation program with a range of new requirements that in some cases mirror trends in regulatory scrutiny. Read more »

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