Insurance

CMS has released additional guidance allowing for flexibility in claims auditing and quality reporting during the transition to the International Classification of Diseases, Tenth Revision and is working with the American Medical Association to educate providers.

California's recent initiatives to address the impact of high priced hepatitis C drugs could not have come at a better time, as a new analysis estimates that the state's projected specialty drug expenditure would be $4.77 billion in the next year alone.

Aetna's purchase of Humana would create a managed care company with $115 billion in revenues, of which 56% would be from government business. In addition, the combined company would have the largest enrollment of members on public exchanges, with 1.7 million members.

The deal combines Humana's 3.2 million Medicare enrollees with Aetna's 1.26 million Medicare enrollees, giving the new combined company a strong position as the baby boomer population ages.

As co-pays and deductibles in Medicare and commercial health plans become more prevalent, so, too, does the temptation to waive them. But beware.

CMS has begun to implement risk adjustment and reinsurance programs, 2 premium stabilization programs of the Affordable Care Act. The report highlighted the estimated reinsurance payments issuer in addition to summary level information on the programs, which helps to keep premiums affordable as well as various coverage options available to consumers.

When The American Journal of Managed Care's ACO and Emerging Healthcare Delivery Coalition met for the most recent Web-based session, the speakers discussed the importance of accountable care organizations as CMS moves forward with new reimbursement schemes and managing high-risk patients through coordinated care.

Despite concerns that Medicare Advantage payment reductions included in the Affordable Care Act would lead to a decline in enrollment, the number and share of beneficiaries enrolling in Medicare Advantage has only continue to climb since the health reform law was enacted.

CMS Open Payments data for 2014 is now available and includes information on 11.4 million financial transactions attributed to over 600,000 physicians and more than 1100 teaching hospitals, totaling $6.49 billion.

Although GOP presidential hopefuls are all campaigning on promises to repeal and replace President Obama's Affordable Care Act (ACA), the last real chance to repeal may have been the 2012 election, according to Avik Roy, senior fellow at the Manhattan Institute.

Two new changes to CMS' ACO Investment Model will help practices in rural areas gain more access to the benefits of accountable care organizations.

The number of Medicare Advantage plans with $0 premiums has been on the decline since 2011, and dropped from 813 in 2014 to 726 in 2015, according to a recent analysis government data by HealthPocket.

Margaret E. O'Kane, president of the National Committee for Quality Assurance will join The American Journal of Managed Care for a Tweetchat on June 26 at 1 pm EST. Follow the discussion and ask your own questions using #AJMCchat.

Among the 20 chronic conditions with the highest impact on the Medicare population, some have no quality measure, which limits Medicare's ability to pay for value.

Concern from Congress about the potential cost of widespread use has kept telehealth from expanding in traditional Medicare. But things are starting to change as ACOs gain the ability to use telehealth, and rule changes allow its use for mental health and other services.

Variation in private spending reflects the ability of the local population to pay for healthcare, whereas variation in Medicare is more driven by health status.

Home healthcare transition from hospitals for diabetic Medicare home healthcare beneficiaries can be improved by identifying risk factors for 30-day readmissions due to ambulatory care—sensitive conditions.

Newly announced fraud charges against 243 individuals involved schemes of approximately $712 million worth in false billings, according to an announcement by HHS. CMS also suspended a number of providers.

The first year of CMS' Independence at Home Demonstration led to both higher quality care and and saved $25 million, an average of $3070 per participating beneficiary.

Aledade, founded by Farzard Mostashari, MD, announced on Monday that it had raised $30 million to support its mission of partnering with independent primary care physicians to create accountable care organizations and further fuel the company's growth.

Some hospitals in the United States are marking up costs approximately 10 times the Medicare-allowed costs. This equals a markup of more than 1000% for the same medical services.

The American Journal of Accountable Care recently interviewed Dr Jain about his decision to join CareMore, CareMore's innovative care model, and his perspectives on US healthcare.

The data-fueled healthcare revolution requires us to share data and share risk to ultimately share rewards andachieve Triple Aim goals.

The authors describe a 3-step framework for how accountable care organizations (ACOs) can ensure that patients' needs, values, and preferences are incorporated into ACO governance decisions.

There was a strong connection between the proportion of patients a physician already had enrolled in hospice care and whether or not other patients would enroll in hospice, according to a study published in Health Affairs.

The Center for Health Policy at Brookings and the USC Leonard D. Schaeffer Center for Health Policy and Economics came together for a half-day forum that concentrated on examining and studying the future of the Medicare program. In a 5-part working paper series, healthcare stakeholders examined trends, asked questions, and formulated proposals that would prepare the Medicare program for this incoming class of seniors.

A study of Medicare claims suggests that policies that ask seniors to pay more out of pocket for prescriptions may lead to lower adherence and result in higher healthcare costs.

Just as diabetes care started the movement toward population management, it is leading the way to new payment models, according to speakers who appeared at a symposium to open the 75th Scientific Sessions of the American Diabetes Association.

We assessed challenges and barriers to annual diabetic eye examinations for a managed care Medicaid population and make recommendations to improve population-level screening.

This week CMS released their third round of annual data, the value-based topics of the American Society of Clinical Oncology gained new ground, and The American Journal of Managed Care will travel to their 75th session of the American Diabetes Association in Boston.