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Preferred network access in Part D under dispute


Amid challenging trends in drug prices and formularies, independent pharmacy advocates are pushing for a new "any willing" provider mandate in Medicare Part D. Read more »

Health systems have a go at Medicaid managed care plans


Of all the health organizations working as Medicaid managed care plans, a good number of provider-based plans are thriving, sometimes in places where traditional Medicaid HMOs are not. Read more »

Legacy pricing allegations end with record settlement


Along with the changes and new costs coming with health reform, past problems are cropping up for some insurers, even setting regulatory records. Read more »

As wellness market booms, challenges emerge


The employer wellness movement is gaining steam globally, but some trends are hitting a wall. Read more »

Claims data a key to changing avoidable ER visits


One state is finding new approaches to managing Medicaid frequent fliers. Read more »

Crackdown may be coming for Medicare Advantage


Federal health officials are increasingly scrutinizing Medicare Advantage risk adjustment, suggesting policy changes and even clawbacks to come. Read more »

More insurers see case for telemedicine


Pretty soon, 24/7 digital access to a physician or nurse practitioner could be a standard health plan benefit. Read more »

Retail healthcare 2.0: A 'new retail price'


Walmart is taking another, bigger step into American healthcare with new primary care services. Is a health plan next? Read more »

Medicaid plans see need for value-based diabetes care


The diabetes crisis and pay-for-value evolution are coming to a head, helping change provider reimbursement in Medicaid. Read more »

In data security, compliance is not everything


There's been a lot of talk about compliance lately. Federal and state regulations. HIPAA regulations. But, if you're in charge of healthcare security, compliance is far from sufficient, according to one large insurer. Read more »

High-value providers beget more competition, payer pilot suggests


Access to prices and just a bit of nudging seems to not only help members find the best deals on elective health services like imaging but also spur some competition among providers. Read more »

Medicaid data shows financial winners and strugglers


At a time when states are both reforming Medicaid and expanding managed care, insurers have a lot of opportunities to grow business and increase value, but also many challenges. Read more »

Are healthcare startups answering the right questions?


Startups and investors from Silicon Valley to the Charles River are chasing after the next paradigm-shifting blockbuster innovation. But are any of new companies developing technology that will truly help transform healthcare? Read more »

Blues create information sharing service as public utility


Two large health insurers are hoping a new "public utility" patient data sharing service will improve one of the most pernicious problems in American healthcare. Read more »

IBC primary care investment takes off


A venture by Independence Blue Cross and a company ranking well in Warren Buffett's portfolio is getting underway, in an ambitious attempt to optimize the benefits of primary care. Read more »

Florida puts managed care to the test


One of the largest Medicaid managed care expansions has been given the green light for what will be a test of reducing public-payer spending. Read more »

Future M&A deals target payers


As provider power grows and integrated healthcare becomes a central goal, the time may become ripe for more payer takeovers of a kind not seen before. Read more »

Exchange touts reasonable premiums for year two


Premiums for exchange plans in California are looking pretty affordable. Is this because insurers are fearful of a rate review process that might be approved by voters in the fall, or a large, diverse market spreading out risk? Read more »

Feds set ICD-10 deadline, again


Well, here we are. The revised compliance date for providers, payers and clearinghouses to transition to ICD-10 has been finalized by the Department of Health and Human Services. Read more »

Start-up insurer embraces telemedicine


Utah's start-up health plan is offering a new service that could prove attractive to employers and individuals in a state with a growing tech hub, while also putting pressure on established players. Read more »

Aetna goes deep on metabolic intervention


More and more, insurers are trying to help members get fit, slim down, and eat better. But for one of this century's most pernicious health problems, some find they need data-driven frameworks to target interventions and gauge their effectiveness. Read more »

California giants want to move needle on accountable care


The San Francisco Bay area is getting a new accountable care organization courtesy of the formation of a new company by two healthcare powerhouses in the region. Read more »

Among uninsured, HIX enrollees, transitioning and would-be markets


A new portrait of the uninsured and newly-insured is emerging, with a confluence of factors shaping who is and isn't enrolling in Medicaid or private plans. Read more »

In autorenewals, beware of market shocks


Among the many challenges in year two of federal exchanges, the process of auto re-enrollment is bringing the potential of convenience and disruption, for both consumers and insurers. Read more »

Providers struggle to make headway on risk


As payers and employers put pressure on providers to assume more financial risk, providers are struggling to assess the impact of the risk they have already assumed. Read more »

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