Payer


  • Congressmen Brendan Boyle and Jodey Arrington lean toward one another while having a seated discussion.
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    Lawmakers promise to stop kicking the can on Medicare solvency

    The House Budget Committee met Thursday and said they’d take action to restore Medicare’s financial footing, though the hearing was light on specifics.

    By June 14, 2024
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    Alex Wong via Getty Images
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    CMMI’s savings record sparks concern among lawmakers

    Republicans at a House subcommittee hearing chided the innovation center for increasing federal spending, even as CMMI’s director said each tested model has resulted in valuable learnings.

    By June 14, 2024
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    RossHelen via Getty Images
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    Trendline

    Social determinants of health

    The focus on social determinants of health has only increased because of the impacts of the pandemic, with payers and providers trying to new ways to address the issues.

    By Healthcare Dive staff
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    Alex Wong via Getty Images
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    CMS recalculates Medicare Advantage star ratings in major win for insurers

    The redo comes after regulators lost two court cases over the methodology used to determine 2024’s quality ratings and should result in hundreds of millions of dollars in additional bonuses to plans.

    By June 14, 2024
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    Foremniakowski via Getty Images
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    National health spending reached $4.8T last year, CMS actuaries estimate

    More Americans had insurance in 2023 than at any other time in the nation’s history, spurring medical utilization and accelerating healthcare spending faster than growth in the overall economy, according to government projections.

    By June 12, 2024
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    Win McNamee via Getty Images
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    MACPAC wants Congress to force states to disclose Medicaid financing streams

    The influential advisory group has been lobbying the federal government to collect more detailed information on how states loop providers into funding Medicaid for almost a decade.

    By June 12, 2024
  • Elevance headquarters is a large white and brown building surrounding a grassy quad.
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    Permission granted by Elevance Health
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    Elevance wins star ratings lawsuit (sort of)

    Friday’s district court ruling is the latest suggesting the CMS might have to recalculate every MA plan’s star rating score due to an administrative oversight.

    By June 11, 2024
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    iStock / Fly View Productions

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    Sponsored by Veradigm

    3 ways value-based care is transforming American healthcare

    This transition to value-based care is transforming the healthcare system. Medical practices can expect many benefits from this transformation—but only after fully embracing the shift.

    By Amanda Cohen, MPH • June 10, 2024
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    ipopba via Getty Images
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    Sponsored by PointClickCare

    Leveraging technology to achieve balance in healthcare

    Leveraging technology is crucial for healthcare to enhance care, automate tasks and optimize outcomes.

    By B.J. Boyle, Chief Product Officer, PointClickCare • June 10, 2024
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    Joe Raedle via Getty Images
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    Affordable Care Act insurers could be on the hook for $1.1B in rebates this year

    Rebates this year could cross the billion-dollar mark for the fifth time in the past decade, according to an analysis from the KFF.

    By June 7, 2024
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    Spencer Platt via Getty Images
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    Deep Dive

    Humana and CVS are downsizing their Medicare Advantage plans for 2025. Which insurers could benefit?

    Hundreds of thousands of seniors could switch plans during next year’s open enrollment, depending on how drastically the MA market giants slash benefits in an attempt to improve profits.

    By Updated June 10, 2024
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    dventtr via Getty Images
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    Scan Health Plan wins Medicare Advantage star ratings lawsuit

    The insurer argued the CMS didn’t follow its stated methodology for calculating quality scores, causing its rating to drop and risking millions of dollars in payments.

    By June 4, 2024
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    Spencer Platt via Getty Images
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    Medicare Advantage sales middleman sues HHS over rule capping broker compensation

    AmeriLife’s suit joins at least two others from MA sales groups seeking revisions to the rule for threatening their business model. It also comes with a clock, given a looming deadline for marketing contract negotiations.

    By June 3, 2024
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    Kameleon007 via Getty Images
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    Move over, Medicare Advantage — UnitedHealth, Centene flag higher Medicaid utilization concerns

    Worries about higher-than-expected medical spending have reached Medicaid, as redeterminations spark turbulence in the program.

    By May 30, 2024
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    Stephen Maturen via Getty Images
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    Minnesota’s Medicaid program to block for-profit insurers from participation

    The ban initially only affects UnitedHealthcare, which is the sole for-profit managed care organization with a Medicaid contract in the state.

    By May 29, 2024
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    Stock via Getty Images
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    Express Scripts’ new partnership is an olive branch to independent pharmacies

    Cigna’s massive pharmacy benefit manager has unveiled a new collaboration with a network of independent pharmacies at a time of rising tension between PBMs and the pharmacies they pay.

    By May 23, 2024
  • Congressmen Brendan Boyle and Jodey Arrington lean toward one another while having a seated discussion.
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    Anna Moneymaker via Getty Images
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    House committee takes aim at healthcare consolidation, eyes site-neutral payments

    Equalizing Medicare payment between sites of service to cut down on provider consolidation is a “no brainer,” one witness testified during the hearing.

    By May 23, 2024
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    Courtesy of Tandem Diabetes Care
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    Medicare adviser sets recommendations for diabetes device evidence

    The panel found time in range was an “extremely important” metric, but members were divided on whether quality of life measures should influence coverage.

    By Elise Reuter • May 22, 2024
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    Latest 340B ruling delivers blow to providers

    Drugmakers are allowed to impose conditions on which pharmacies they dispense discounted drugs to in the 340B program, according to an appellate court.

    By May 22, 2024
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    Courtesy of UnitedHealth Group
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    UnitedHealth’s Optum Rx unveils new drug pricing model

    Major pharmacy benefit managers are rolling out a flurry of ostensibly transparent and cost-effective models to retain clients and placate scrutiny over their role in rising drug costs.

    By May 21, 2024
  • Sen Ron Wyden sits behind a wooden podium with a microphone.
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    Sarah Silbiger / Stringer via Getty Images
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    Senate Finance Committee tackles Medicare physician pay reform

    On Friday, the committee released a white paper proposing Medicare adjust doctor reimbursement to account for inflation, a key goal for physician lobbies.

    By May 20, 2024
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    ChrisBoswell via Getty Images
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    Kansas jilts CVS in new Medicaid contract awards

    Kansas kicked CVS to the curb in favor of an Elevance plan, while awarding contracts to incumbents UnitedHealth and Centene. The contracts are worth roughly $4 billion annually.

    By May 15, 2024
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    FangXiaNuo via Getty Images
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    Hospitals charged employers and insurers 254% more than Medicare in 2022: study

    Hospitals with larger market shares were among the worst offenders, the Rand Corporation found.

    By May 14, 2024
  • Humana CEO Bruce Broussard
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    Michael Loccisano / Staff via Getty Images
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    Humana CEO Bruce Broussard to depart July 1

    At that time, current Chief Operating Officer Jim Rechtin will take the reins of the health insurer, which is struggling with challenges in Medicare Advantage.

    By May 14, 2024
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    400tmax via Getty Images
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    Deep Dive

    Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1

    All major payers saw elevated utilization but only an unprepared few struggled with the trend, the Change Healthcare cyberattack caused minimal financial fallout and a new D-SNP rule opens the door to a Medicare growth opportunity.

    By May 13, 2024
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    yavdat via Getty Images
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    CHS sues MultiPlan for allegedly colluding to lower provider reimbursement

    It’s the third lawsuit filed against MultiPlan by a health system in under a year.

    By May 10, 2024