Payers

Commercial insurers, the employer and individual market, plus Medicare trends, Medicare Advantage, & Medicaid managed care

Frank Diamond
The rate of increase of health care costs was less over eight years for beneficiaries enrolled in a value-based program in which participating physicians took on two-sided risk, compared with a control group seen by providers with traditional contracts, according to a study published in the New England…
Cover Story
Joseph Burns
Rebates have created pay-to-play dynamics. Employers facing high drug costs have “rebate addiction.” And the impressive “rebate guarantees” are hard to resist. But at least the process of how drugs get formulary placement is becoming clearer, and some PBMs have moved to charging administrative fees only.
Innovation ’19: Reverse Auctions for PBMs
Joseph Burns
The state used a reverse auction whose rounds of bidding saved $1 billion on PBM services, according to the consultant who helped orchestrate the deal. Other states (maybe Maryland) and large purchasers may follow suit.
Innovation ’19: Blockchain
Richard Mark Kirkner
Competitors are coming together to see if they can leverage blockchain’s magic to solve big problems. Provider directories are among the first use cases.
Innovation ’19: AI
Sarah Kwon
The evidence base is wobbly, but artificial intelligence is coming on strong and the hype for it is even stronger. Screening for diabetic retinopathy is an early application. Lingering questions include whether the use of AI will contribute to health care inequities rather than solve them.
Innovation ’19: Survey Results
We had 180 respondents to our emailed survey between May 30 and June 10. Artificial intelligence for screening received the most “game changer” votes; installment payments for specialty drugs led in “never will gain traction.” If you missed the emailed survey, you can fill out it now on our…
News & Commentary
Frank Diamond
Mai Pham, MD, Anthem (left);
Kelly Macken-Marble, South Bend Clinic
Under Anthem’s recently launched Cooperative Care program in South Bend Clinic in Indiana, the ACO’s 150 providers will take on two-sided risk. Cooperative Care also focuses on data sharing and quality measurement as part of a targeted program to bypass prior authorization for select services in which providers have high rates of requests and approvals.
Original Research
Adam E. Block, PhD
Crystal Run will close its health plan at the end of this year. Its losses in the small-group market were driven, in part, by risk adjustment. But another major factor was excessive administrative costs, which were three times as high as the administrative costs at established health plans.