Value-based healthcare
Value-based care is a reimbursement model wherein payers compensate providers based on key metrics for care quality, care coordination and health outcomes. Value-based care aims to reduce healthcare costs and improve patients’ experience and health by using health information technology for data collection, analysis and sharing among providers.
Top Stories
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Feature
05 Dec 2024
5 pillars that underpin payer population health strategies
The healthcare system faces many challenges, but by focusing on these five pillars, payers can establish holistic and effective population health strategies. Continue Reading
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News
05 Aug 2024
Members rarely challenge coverage denials, surprise billing
Only 45% of individuals who received a surprise bill challenged it and only 43% of those who were denied coverage appealed the decision. Continue Reading
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22 Feb 2022
AHIP: Next Steps Toward Primary, Behavioral Healthcare Integration
The payer organization outlined the current top strategies around behavioral healthcare integration and suggested ways that the healthcare industry could make progress. Continue Reading
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22 Feb 2022
Top 10 Most Expensive Chronic Diseases for Healthcare Payers
The top 10 most expensive chronic diseases for healthcare payers eat up significant healthcare dollars. Continue Reading
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18 Feb 2022
30% of Seniors Still Experience Impacts of Foregone, Delayed Care
Seniors continue to experience foregone and delayed care, which impacts payer revenue and spending. Continue Reading
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14 Feb 2022
Low Value Care Spending on Low Back Pain Is Decreasing
Low back pain, along with neck pain, is a source of high healthcare spending overall, particularly low value care spending, but the industry may be making progress. Continue Reading
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10 Feb 2022
CMS Home Healthcare Policy Reduced Hospital Readmissions
Patients who received post-discharge home healthcare under the CMS PACT policy experienced lower rates of hospital readmissions. Continue Reading
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Answer
10 Feb 2022
Applying Whole Person Care to Digital Care for Underserved Members
Too often Medicaid beneficiaries receive transactional care, but payers can leverage digital solutions such as e-consulting services to advance whole person care. Continue Reading
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Answer
02 Feb 2022
How to Hone Wellness Programs Using Social Determinants Data
Payers and employers can collaborate to create more effective wellness programs by leveraging social determinants of health data from community sources. Continue Reading
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27 Jan 2022
3 Ways to Assess ROI on Social Determinants of Health Programs
Social determinants of health programs are notoriously difficult to evaluate when it comes to return on investment, but payers and their partners are finding ways to assess the outcomes. Continue Reading
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20 Jan 2022
Payer, Provider Collaboration May Improve Provider Directories
Timely communication between payers and practices, streamlining data collection and submission, and updating information can improve health plan provider directories. Continue Reading
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19 Jan 2022
How Employers Can Address Employee Needs, Social Determinants
Employers should prioritize demographic data, community partnerships, and multiple intervention strategies to successfully address employees’ social determinants of health. Continue Reading
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19 Jan 2022
Top Employer Strategies for Implementing Episodes of Care Models
Employers looking to enter into episodes of care models should consider seizing control of their own data and engaging in direct contracting with providers. Continue Reading
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17 Jan 2022
COVID-19 Federal Spending Drove National 2020 Healthcare Spending
Federal dollars that went toward pandemic-related actions and initiatives were the driving force behind the increase in national healthcare spending in 2020. Continue Reading
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05 Jan 2022
Low Value Care in Pediatric, Inpatient Care Cost $17M in 2019
Low value care was especially costly in bronchiolitis and pediatric behavioral healthcare, despite the industry’s efforts to divert low value care in these cases. Continue Reading
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30 Dec 2021
Hospitalization of Unvaccinated COVID-19 Patients Cost $13B
Unvaccinated COVID-19 patients may have contributed over $13 billion to the national healthcare spend from June 2021 through November 2021. Continue Reading
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27 Dec 2021
Children, COVID-19 Are Drivers of Household Healthcare Spending
COVID-19 diagnoses and children were associated with more instances of high out-of-pocket household healthcare spending. Continue Reading
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13 Dec 2021
How Value-Based Care Can Support Efforts to Address Health Equity
Value-based care provides a pathway to remove barriers to health equity by addressing social determinants of health. Continue Reading
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10 Dec 2021
The Impact of In-Home Chronic Disease Management on Spending
In-home chronic disease management services may have reduced healthcare spending for patients with certain diseases by nearly $30,000. Continue Reading
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09 Dec 2021
Most Adults Have Low Health Literacy, Strong Medical Bill Concerns
Low health literacy among adults can prevent members from fully understanding their benefits, leading to confusion about coverage and unexpected medical bills. Continue Reading
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News
07 Dec 2021
How Payers Can Expand Nutritional Benefits, Measure Impact
Reducing food insecurity is key to improving an individual’s health, but payers are still exploring how nutritional benefits can best serve their member populations. Continue Reading
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07 Dec 2021
UHG Report Finds Encouraging Trends During The Coronavirus Pandemic
The coronavirus pandemic has had a massive, negative impact on the nation’s health and healthcare, but some trends are also improving during this difficult time. Continue Reading
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01 Dec 2021
High Deductibles Associated with More Medical Bill Problems
While the number of adults with medical bill problems decreased between 2013 and 2015, high deductible health plans, low income levels, and uninsurance contributed to a greater likelihood of payment struggles. Continue Reading
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News
17 Nov 2021
Humana Shares 2020 Medicare Advantage Value-Based Care Results
Medicare Advantage value-based care had an impact on hospitalizations, preventive care services, and healthcare spending during the coronavirus pandemic. Continue Reading
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16 Nov 2021
How A Rare Condition Can Fuel Medicaid Spending, Utilization
Sickle cell disease may impact a small portion of the Medicaid population, but this community of beneficiaries has high Medicaid spending and emergency care utilization. Continue Reading
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09 Nov 2021
Centene Highlights Ways to Improve Mental Healthcare for Children
Payers can take steps to improve mental healthcare for children as the coronavirus pandemic continues to impact children’s development. Continue Reading
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04 Nov 2021
12% of Payers Implement 10 or More Outcomes-Based Contracts
Outcomes-based contracts help further value-based care aims, reimbursing pharmaceutical companies for value instead of volume. Continue Reading
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28 Oct 2021
VA Demonstrates How Health Plan Network Size Impacts Utilization
As many payers in the health insurance industry strive to downsize their networks to cut costs, the Department of Veterans Affairs saw utilization grow by expanding health plan network size. Continue Reading
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26 Oct 2021
CMMI Aims to Lower Out-of-Pocket Healthcare Spending by 2030
CMMI outlined its goals for lowering out-of-pocket healthcare spending—and healthcare spending overall—in the next decade. Continue Reading
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20 Oct 2021
COVID-19 Out-of-Pocket Spending Lower with Cost-Sharing Waivers
Few patients had high out-of-pocket spending for facility services during a COVID-19 hospitalization, indicating that services cost-sharing waivers may have covered the costs. Continue Reading
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12 Oct 2021
How Payers Leverage Apps to Improve Type 2 Diabetes Management
Apps are common Type 2 diabetes management tools, but with so many options on the market how can payers identify and implement these solutions successfully? Continue Reading
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08 Oct 2021
Behavioral Health, Physical Health Worsen Among Women, Children
Behavioral health and physical health indicators among women of reproductive age and children in the US trended in a negative direction, but certain health behaviors improved. Continue Reading
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30 Sep 2021
How Benefit Design Can Steer Employees Toward High-Value Care
Employers play a key role in aligning benefit design and payment reform efforts around high-value care. Continue Reading
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27 Sep 2021
How Employers Can Control Costs with Episode-Based Benefit Plans
Employers can use cost-sharing levers around episode-based benefit plans to reduce low value care among employees. Continue Reading
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23 Sep 2021
5 Steps Employers Can Take To Implement Advanced Primary Care
Although large employers are interested in leveraging some advanced primary care strategies, many do not know how to scale these efforts to produce significant results. Continue Reading
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Answer
22 Sep 2021
The State of Payer, CBO Social Determinants of Health Contracting
Health plans and community-based organizations face numerous challenges in the new world of social determinants of health contracting. Continue Reading
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21 Sep 2021
3 Strategies for Sustaining Payer Innovation Momentum Post-COVID
The coronavirus pandemic resulted in accelerated payer innovation and payers can continue that momentum by identifying opportunities, involving members, and using data effectively. Continue Reading
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10 Sep 2021
Top 3 Member Engagement Benefits of Using Omnichannel Tools
Member engagement received a boost from increased telehealth utilization, but omnichannel strategies may prove key to continuing that success. Continue Reading
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08 Sep 2021
How Ambulatory Surgery Centers Lower Payer Outpatient Spending
Payers can reduce surgical costs by 59 percent by shifting eligible members from the hospital outpatient setting to ambulatory surgery centers. Continue Reading
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31 Aug 2021
Essential Home Healthcare Quality Measures for Value-Based Care
Based on CMS home healthcare quality measures for Medicare home health agencies, payers can establish strong quality measures with their home healthcare partners. Continue Reading
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26 Aug 2021
Employers: Mental Health, Chronic Disease Needs Will Rise in 2022
Mental health and chronic disease needs will increase as employees face the long-term effects of the coronavirus pandemic in 2022, employers predict. Continue Reading
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25 Aug 2021
Unvaccinated COVID-19 Hospitalizations Drive Up Healthcare Spend
The costs of unvaccinated COVID-19 hospitalizations are high due to the higher number of unvaccinated individuals who contract COVID-19. Continue Reading
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05 Aug 2021
Value-Based Care Challenges, Opportunities for Payers in 2021
As the country continues to wrestle with the implications of the coronavirus pandemic, payers face unique value-based care challenges and opportunities. Continue Reading
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02 Aug 2021
5 Ways Payers Have Tackled Mental, Behavioral Healthcare in 2021
As the coronavirus pandemic becomes more manageable and vaccination rates increase nationwide, payers are channeling funds into mental and behavioral healthcare programs. Continue Reading
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News
27 Jul 2021
Why Catastrophic Medicare Part D Drug Spending Is On The Rise
For more than a decade, catastrophic Medicare Part D drug spending has impacted a growing number of Medicare beneficiaries and consumed a high amount of overall drug spending. Continue Reading
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14 Jul 2021
How Payers Can Support Population-Based Payment Model Uptake
Public and private payers alike play a role in increasing value-based care progress by boosting population-based payment model adoption. Continue Reading
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Answer
12 Jul 2021
How Payers Can Improve Cancer Patient Navigation, Experience
Cancer patient navigation through the healthcare system is notoriously challenging, but payers can help states improve that reputation. Continue Reading
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News
01 Jul 2021
How Employers Can Influence Employee Coronavirus Vaccine Uptake
Coronavirus vaccine uptake continues to be key to recovery from the pandemic, but as the public grows more relaxed about COVID-19 employers’ roles may be even more critical. Continue Reading
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28 Jun 2021
Going Beyond Compliance: How Payers Can Embrace Healthcare Interoperability
CMS is requiring healthcare interoperability from payers but embracing more data-sharing with the consumer in mind will be key to future success for health plans. Continue Reading
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23 Jun 2021
87% of Eligible Seniors Do Not Receive Lung Cancer Screenings
Lung cancer screenings were higher among Medicaid beneficiaries in states that covered the preventive service. Continue Reading
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17 Jun 2021
Racial Care Disparities May Be Lower in Medicare Advantage Plans
Medicare Advantage members were more likely to receive preventive services and have lower out-of-pocket healthcare spending, with lower racial care disparities. Continue Reading
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17 Jun 2021
Pros, Cons of Non-Emergency Medical Transportation Benefits
MACPAC’s June 2021 report to Congress included findings about non-emergency medical transportation benefits in Medicaid programs that could prove useful for benefits design. Continue Reading
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10 Jun 2021
4 Payers That Have Embraced Value-Based Care Models in 2021
In the first six months of 2021, payers have continued to strike deals that involved value-based care models despite the effects of the coronavirus pandemic. Continue Reading
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News
10 Jun 2021
Wellness Programs May Not Significantly Impact Healthcare Spending
A wellness program study demonstrated no significant impact on members’ health, healthcare spending, or employment outcomes. Continue Reading
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02 Jun 2021
ARP Boosted Funding for Home, Community-Based Services, SDOH
The American Rescue Plan increased the federal matching rate for home and community-based services by 10 percentage points. Continue Reading
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26 May 2021
How MA Plans Can Build on COVID-19 Home Healthcare Strategies
Medicare Advantage plans can build on coronavirus home healthcare strategies such as bundling social determinants of health services and leaning into remote patient monitoring. Continue Reading
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24 May 2021
USPSTF Recommendations Guide Payers on Preventive Care Screenings
The latest US Preventive Services Task Force recommendations addressed hypertension, colorectal cancer, and vitamin D deficiency preventive care screenings. Continue Reading
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20 May 2021
UHG Reviews Senior Social Determinants of Health Pre-Pandemic
Before the pandemic, seniors faced a number of social determinants of health challenges that remain pertinent for payers to address. Continue Reading
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19 May 2021
Cancer Patient Outcomes Significantly Worse for the Uninsured
Survival rates for cancer patients without insurance are drastically lower than patients who are insured, highlighting the connection between insurance access and patient outcomes. Continue Reading
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17 May 2021
Employer-Sponsored Wellness Programs Boost Employee Morale
Employer-sponsored wellness programs can help employees meet their mental healthcare, financial wellness, and physical wellness goals. Continue Reading
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13 May 2021
How AI Supports Low-Risk Member Identification, Care Management
Identifying and providing care management for low-risk members can be tricky for payers, but AI and machine learning can help. Continue Reading
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10 May 2021
Strategies for the Physical-Behavioral Healthcare Integration Puzzle
Leveraging value-based care, correctly assessing the technology’s capabilities, and empowering primary care are at the heart of physical and behavioral healthcare integration. Continue Reading
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04 May 2021
Humana Joins Traditional Medicare Value-Based Contracting Model
The traditional Medicare value-based contracting model includes 53 direct contracting entities that will serve traditional Medicare beneficiaries across 38 states and the District of Columbia. Continue Reading
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03 May 2021
Gross Margins, MLRs May Confirm Payer Profitability in 2020
Although the results are still tentative without administrative cost data, researchers indicated that payer profitability may have increased in four health insurance markets. Continue Reading
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03 May 2021
High Health Plan Costs Serve as Healthcare Coverage Barrier in TX
More than 20 percent of Texans reported that they do not have access to health insurance, compared to 13 percent of national survey respondents. Continue Reading
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29 Apr 2021
Employers: Healthcare Spending Is on an Unsustainable Trajectory
While most employers in the study indicated that they had some control over healthcare spending in their companies, they also supported some government interventions. Continue Reading
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29 Apr 2021
Key Considerations For Implementing Diabetes Management Programs
For payers looking to create or bolster diabetes management programs, it is critical to address mental health, include wellness programming, and persist in member engagement. Continue Reading
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26 Apr 2021
How to Overcome Challenges in Gathering Racial, Ethnicity Data
Payers can boost their race and ethnicity data by recognizing members’ legitimate concerns, communicating clearly, and leveraging indirect data more accurately. Continue Reading
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26 Apr 2021
Value-Based Care Best Practices: A Phased Approach
More physicians are joining value-based and risk-based models to navigate uncertain financial times. Continue Reading
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16 Apr 2021
Payer Launches Value-Based Kidney Care Agreement for CKD, ESKD
The value-based kidney care agreement includes care coordination and home healthcare goals as well as an awareness campaign for both primary care providers and members. Continue Reading
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15 Apr 2021
Social Risk Adjustment Promotes Health Equity In Value Based Care
To ensure safety-net hospitals are not penalized under value-based payment programs, researchers contend that reimbursement should be contingent upon social risk factors. Continue Reading
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12 Apr 2021
Employer Strategies For Responding to the Mental Health Crisis
As the behavioral and mental health crisis grows, employers can leverage preventive care, collaborative care, employee assistance programs, and data to respond. Continue Reading
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06 Apr 2021
Disparities in Pediatric HMO Enrollment Draws Care Access Concern
Hispanic and Black children are enrolled in HMOs at higher rates than White children, drawing potential care access and health disparity concerns. Continue Reading
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05 Apr 2021
AHIP Releases A Resource for ACA Special Enrollment Awareness
The ACA special enrollment period could reverse coverage disparity trends, but for it to fulfill that mission payers need to provide clear guidance about enrollees’ coverage options. Continue Reading
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31 Mar 2021
Payer Seeks to Balance In-Person, Virtual Mental Healthcare
Aetna and CVS Health aim to provide an omnichannel approach to mental healthcare by mirroring their in-person HealthHUB options with a virtual care option. Continue Reading
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30 Mar 2021
Payer Platform for Self-Funded Employers Targets Member Engagement
For self-funded employer clients that want to streamline their healthcare offerings and increase member engagement, payer digital platforms can provide solutions. Continue Reading
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25 Mar 2021
How Payers Can Identify, Reduce Low Value Care Spending Patterns
Identifying and eliminating low-value care spending will be crucial to improving overall healthcare spending and patient outcomes. Continue Reading
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10 Mar 2021
3 Ways to Cut Payer, Employer Gene Therapy Healthcare Spending
CVS Health’s report shared three strategies that payers can continue to rely on in 2021 as they grapple with increased gene therapy healthcare spending. Continue Reading
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01 Mar 2021
Rare Disease Healthcare Spending Tops Costly Chronic Diseases
Rare disease healthcare spending totaled around $966 billion in 2019, which exceeds the amount spent for most of the top chronic diseases like cancer and diabetes. Continue Reading
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17 Feb 2021
Healthcare Spending Frequency Impacts Affordability for Members
For approximately 40 percent of commercial members, one engagement with the healthcare system was responsible for nearly half of their annual healthcare spending. Continue Reading
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11 Feb 2021
Humana Launches MA Value-Based Care Model, Hospice Care Coordination
Eligible Medicare Advantage beneficiaries now have access to a value-based hospice care model that is expected to enhance care coordination. Continue Reading
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09 Feb 2021
COVID-19 Delays Value-Based Care Contract Negotiations
Value-based contracting has slowed amid the COVID-19 pandemic, revealed the second annual Value-Based Care Assessment from Insights by Xtelligent Healthcare Media. Continue Reading
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08 Feb 2021
How Payers Can Improve Care Management To Enhance Quality, ROI
To improve their care management strategies, payers can better identify sources of value, target the right kind of healthcare spending, bolster consumerism, and use operational metrics. Continue Reading
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12 Jan 2021
CMMI Shares Lessons on Value-Based Care from Its First Decade
Center for Medicare and Medicaid Innovation has released an overview of its value-based care models and lessons learned. Continue Reading
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11 Jan 2021
Payers Kick Off 2021 Investments in Social Determinants of Health
As the US continues to experience exacerbated social determinants of health issues, some payers are starting the year by investing in housing, food, and health equity. Continue Reading
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07 Jan 2021
Medicaid Expansion May Boost Homeless Individuals’ Access to Care
In Arkansas, utilization of healthcare services among the homeless community spiked after Medicaid expansion, implying that Medicaid expansion may be associated with access to care. Continue Reading
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06 Jan 2021
Payers, Patients Save With Value-Based Chronic Disease Management
Highmark’s value-based care agreement with a type 2 diabetes drug firm lowered payer and patient chronic disease management costs by 20 percent. Continue Reading
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31 Dec 2020
3 Ways That Payers Leveraged Artificial Intelligence in 2020
Artificial intelligence supported payers’ strategies around industry goals such as value-based care, member engagement, and medication adherence. Continue Reading
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31 Dec 2020
In 2020 Consumerism Will Steer Payer Decisions in Deals, Spending
While consumerism in healthcare is nothing new, it will play an even greater role in how payers make deals, use technology, hire, pursue equity, and spend. Continue Reading
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30 Dec 2020
SDOH Awareness, Care Coordination Key to Payer Leader Development
Payers can help shape future leaders by reinforcing social determinants of health awareness and supporting collaborative care coordination. Continue Reading
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22 Dec 2020
How to Rethink Population Health Management for Rare Disease Care
In order to improve population health management for patients with rare diseases, payers may need to rethink member identification and modify traditional member engagement strategies. Continue Reading
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18 Dec 2020
Ambulatory Surgery Centers Could Save Private Payers $3B
When members select an ambulatory surgery center for joint replacement surgeries, their decision can have positive implications for payers’ healthcare spending. Continue Reading
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16 Dec 2020
How Payers Can Drive A Quicker Transition to Value-Based Care
A Blue Cross and Blue Shield of North Carolina executive shares how the payer quickly shifted its membership toward value-based care agreements from 2019 through 2020. Continue Reading
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11 Dec 2020
Chronic Disease Management, Preventive Care Improved in 2019
While certain chronic disease management and preventive care measures improved in the US in 2019, other challenges such as obesity rates and mental healthcare needs continued to thrive. Continue Reading
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03 Dec 2020
Medicare Value-Based Contracting Model Emphasizes Care Coordination
In the new Medicare value-based contracting model, participating organizations take on full risk and receive payments based on outcomes. Continue Reading
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02 Dec 2020
More Employers Offer Employer-Sponsored Same-Sex Spousal Coverage
An increasing number of employers are offering employer-sponsored same-sex spousal coverage, particularly in large firms. Continue Reading
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24 Nov 2020
How Employers, Payers Can Pursue Integrated Health Care Benefits
As employers pursue integrated health care benefits, payers can better support their employer partners by being aware of this solution and sharing relevant outcomes data with their partners. Continue Reading
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12 Nov 2020
How an AI App Navigates Narrow Networks, Cuts Healthcare Spending
High healthcare spending is rampant across the US, but Anthem Blue Cross is using an exclusive provider organization and an artificial intelligence app to control costs. Continue Reading
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09 Nov 2020
Special Needs Plans Improve ESRD Patient Outcomes, Lower Mortality
ESRD patient outcomes in chronic condition special needs plans reflect lower mortality and lower hospitalization than their non-enrolled counterparts. Continue Reading
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06 Nov 2020
Consumers Use Digital Tech for Price Comparison, Virtual Care
The survey found that 55 percent of respondents reported using digital devices for price comparison and 56 percent were interested in using them for virtual care. Continue Reading
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05 Nov 2020
2 Mistakes Payers Can Avoid in Mental, Behavioral Health Screenings
Payer mental and behavioral health screenings can fall victim to two problems: the language is inaccessible for members or members may not receive actionable next steps once diagnosed. Continue Reading
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03 Nov 2020
Lessons from Medicaid on Social Determinants of Health Innovation
Medicaid programs display diverse approaches to social determinants of health that can help guide the payer industry’s efforts in this area. Continue Reading