Will there be some Obamacare rate shock in 2015?

Robert Laszewski

Hanging around actuaries as long as I have, one of the old sayings I picked up was: "Figures don't lie, but liars figure."

Payer-provider transactions are evolving

Tom Dean, Emdeon

Like many other industries, from manufacturing to retail, healthcare is looking to use information technology to transform and automate financial payments. Providers, though, have a lot of old and new choices.

A more complete picture of Pioneer ACOs

Larry Kocot and Mark McClellan, MD

The Centers for Medicare and Medicaid Services recently released more detailed ACO-level data for participants for the first two years of the Pioneer ACO Model. Despite the decline in participation and mixed results so far, upcoming regulatory may help.

CMS rulemaking lags cost millions

Debra McCurdy

The Office of Inspector General at the U.S. Department of Health and Human Services continues to fault the Centers for Medicare & Medicaid Services for failing to issue final regulations to enforce the location requirements for rural health clinics.

Medicare Advantage plans can prepare for compliance reviews

Tonya Teschendorf, Cody Consulting

Conformity with CMS compliance guidance requires highly efficient communication and effective collaboration between a number of operative departments throughout a health plan.

As healthcare becomes more integrated, information exchange is more critical

Charlotte Hovet, MD, Dell Healthcare Services

The new payment models in the healthcare marketplace all provide incentives for coordinated care as a means of improving outcomes and lowering costs, especially for chronic diseases. As a consequence, 2014 looks to be the year of the health information exchange (HIE).

Door-to-balloon-time and the perils of quality metrics

Aaron Segal, MD, and Richard Young, MD

"The ER doctor ordered the heart cath, so I just went ahead and did it. Besides, if I didn’t do the cath it would make our door-to-balloon-time quality score go down."

Non-preferred drugs under fire

Charles Ornstein, ProPublica

Some insurers are being accused of violating the spirit of health reform, by forcing people with a variety of illnesses, including Parkinson's disease, diabetes and epilepsy, to pay more for their drugs.

Are payers using clinical data effectively enough?

Gokul Gangadharan, CitiusTech

With increasing regulatory pressure, payers are keen to adopt new technologies, improve efficiencies, implement analytics and build interoperable platforms, but are left looking for ways to access clinical data from providers and other caregivers. The challenge is often in getting a single, standard view of patient data and translating this data into actionable intelligence.

Consumer complexity, confusion to come in open enrollment

Robert Laszewski

It's been pretty quiet lately on the Obamcare front, but that is about to change. To say this fall's open-enrollment has the potential to be problematic is an understatement.


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