Tag: Value Based Care

The 2025 Healthcare Perfect Storm: How Rising Costs and Increased Scrutiny Impact Insurers

The blog post examines the health insurance industry’s challenges in 2025, highlighting rising healthcare costs, increased patient demand, and heightened government scrutiny. Insurers, particularly those focused on Medicare Advantage, must reevaluate strategies to maintain profitability. Despite these hurdles, opportunities for innovation and growth exist through personalized care and strategic partnerships.

This blog post delves into the complex challenges facing the health insurance industry in 2025, a year poised to be a pivotal moment for insurers, particularly those heavily invested in Medicare Advantage plans. Rising healthcare costs, increased patient demand, and heightened government scrutiny are converging to create what we’re calling a “perfect storm.” This confluence of factors threatens profitability and necessitates a critical reevaluation of existing operational strategies. This post expands on the themes discussed in our latest podcast episode, exploring these challenges in greater depth and offering insights into potential solutions for both insurers and healthcare providers.

Rising Healthcare Costs: A Looming Crisis

The escalating cost of healthcare is arguably the most significant challenge facing insurers. Inflation, technological advancements, and the increasing complexity of medical treatments all contribute to this unsustainable upward trend. The post-COVID surge in patient utilization, with many seeking deferred procedures, has exacerbated the problem, placing immense pressure on insurers’ financial reserves. This increased demand is straining existing resources and impacting profitability, pushing medical loss ratios (MLRs) higher than ever before. The implications are profound, forcing insurers to re-evaluate pricing strategies, negotiate more effectively with providers, and explore innovative cost-containment measures.

The Impact on Medicare Advantage

Medicare Advantage (MA) plans, once considered a goldmine for insurers, are particularly vulnerable in this environment. The increased demand for MA plans, coupled with rising healthcare costs, is squeezing profit margins. Major players like Humana and UnitedHealth Group, heavily reliant on MA for revenue, are grappling with these challenges head-on. Their financial performance is becoming increasingly dependent on their ability to manage costs efficiently while maintaining patient satisfaction and adherence to regulatory requirements.

Increased Patient Demand: A Double-Edged Sword

While increased patient demand initially appears beneficial, in the context of rising costs, it becomes a major challenge. Insurers are faced with a difficult balancing act: fulfilling the needs of a growing patient population while simultaneously controlling costs and maintaining profitability. This necessitates a shift towards more proactive and personalized care models that prioritize preventative measures and disease management. Strategic partnerships with providers are crucial for achieving these goals.

The Need for Personalized Care

The sheer volume of patients requires a move beyond traditional, reactive models of care. Personalized care, driven by data analysis and predictive modeling, is becoming essential for identifying high-risk individuals and implementing targeted interventions. This approach not only improves patient outcomes but also helps to manage healthcare costs more effectively, ultimately impacting the MLR and safeguarding insurer profitability.

Increased Government Scrutiny: Navigating Regulatory Hurdles

The health insurance industry is facing unprecedented levels of government scrutiny. Lawmakers are increasingly focused on issues of transparency, affordability, and access to care. This heightened scrutiny translates into stricter regulations, increased audits, and potential penalties for non-compliance. Insurers must navigate this complex regulatory landscape while ensuring they maintain ethical and transparent practices.

Adapting to Regulatory Changes

The regulatory environment is constantly evolving, requiring insurers to be adaptable and proactive. Staying informed about new regulations, investing in compliance programs, and engaging with policymakers are crucial for navigating this challenging landscape. Failure to adapt could lead to significant financial penalties and reputational damage.

Opportunities Amidst the Storm

While the challenges are significant, the current climate also presents opportunities for innovation and growth. Entrepreneurs and healthcare providers can leverage this disruption by focusing on high-cost patient areas and developing innovative solutions that improve efficiency and reduce waste within the healthcare system. New models of care, such as value-based care, offer potential avenues for both improved patient outcomes and reduced costs.

Innovation in Healthcare Delivery

The need for cost-effective and efficient healthcare delivery models has never been greater. Entrepreneurs are stepping up to the plate, developing innovative technologies and solutions to address these challenges. These range from telehealth platforms and remote monitoring devices to AI-powered diagnostic tools and personalized treatment plans. Insurers that embrace these innovations and forge strategic partnerships with these innovators will be better positioned to thrive in the evolving healthcare landscape.

Conclusion

The healthcare industry in 2025 faces a perfect storm of rising costs, increasing patient demand, and intensified regulatory scrutiny. Insurers, especially those heavily reliant on Medicare Advantage, are experiencing significant financial pressure. This necessitates a complete re-evaluation of operational strategies, focusing on cost containment, personalized care, and proactive compliance. However, amidst these challenges lie significant opportunities for innovation and growth. By embracing new technologies, fostering strategic partnerships, and prioritizing patient-centric care models, both insurers and healthcare providers can navigate this turbulent environment and emerge stronger. To delve deeper into this topic and explore potential opportunities, please listen to our podcast episode, “2025 Opportunities in Healthcare: Navigating the Perfect Storm.” This episode provides further insights into the challenges and opportunities discussed in this blog post and offers actionable strategies for navigating the complexities of the 2025 healthcare landscape.

Companies mentioned in this episode:

Research Links:

The Definitive Playbook for Choosing Behavioral Health Markets – Value Based Care Advisory (VBCA) Podcast

Rate sheets don't tell the whole story.In this episode, Alex Yarijanian breaks down the 8-indicator playbook he uses to evaluate any tele-behavioral health market before committing capital — and names the specific states he'd enter today and why.Most operators default to the biggest states: California, Texas, Florida, New York. But population size alone is one of the weakest predictors of a winning market. The real levers live in parity law enforcement, workforce economics, MCO concentration, and infrastructure readiness.WHAT YOU'LL LEARNWhy the biggest states are rarely the best markets for tele-behavioral healthThe 8 indicators that separate win-win markets from cheap-rate miragesHow to build a weighted scoring model before entering a new marketWhat associate-level billing eligibility does to your workforce marginsHow MCO concentration affects contracting speed and rate-cut riskWhich states Alex rates as best all-around, high-risk, and growth-stage betsTHE 8 MARKET INDICATORSMedicaid market size: Total addressable population and realistic capture potentialPayment parity: State-level mental health parity laws and strength of enforcementCost of living index: The single best proxy for labor margin on clinical staffAssociate-level billing: Whether licensed associates can bill independentlyHRSA HPSA demand mapping: Documented unmet need in mental health shortage areasBroadband & 5G coverage: Infrastructure required for reliable telehealth deliveryMCO landscape: Plan count, behavioral carve-outs, any-willing-provider law exposureTax & corporate climate: State-level business environment and regulatory postureMARKET ARCHETYPESBest all-around: Arizona, Nebraska, Delaware, OregonVolume, thin margins: Arkansas, North DakotaHigh rate, high cost niche: AlaskaGrowth stage bets: New Mexico, Montana4 ACTION STEPSBuild a scroll scoring model — layer all 8 indicators into a weighted scorecardValidate demand on the ground — overlay HRSA HPSA maps + FCC broadband gap dataCheck your plan mix — count Medicaid MCOs and behavioral carve-outsRun a payroll stress test — model cost of living vs. your target clinician pay bandRESOURCES MENTIONED HRSA Mental Health HPSA maps: data.hrsa.govFCC broadband coverage maps: broadbandmap.fcc.govNCSL mental health parity law trackerLicensure compact maps: PSYPACT, ASWB Compact, Nurse Licensure Compact State Medicaid rate databases
  1. The Definitive Playbook for Choosing Behavioral Health Markets
  2. Medicare Negotiates Like an Owner. Commercial Doesn’t.
  3. The Rural Health Transformation Fund: What States Are Funding in 2026
  4. Medicare Advantage 2026: How Payers Are Choosing Partners
  5. Digital Health at a Crossroads: The Fallout from a $100M Adderall Fraud Scheme

Understanding State-Level Variation in Medicaid Managed Care Maternity Kick Payments

Understanding State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care

Introduction

Today, we’re exploring an intriguing study on the state-level variation in supplemental maternity kick payments in Medicaid managed care. This study, conducted by Samantha G. Auty, Jamie R. Daw, and Jacob Wallace, provides valuable insights into how these payments impact delivery costs and care quality.

Post Introduction

In this post, we’ll break down the key findings of the study, understand the implications of kick payments on Medicaid managed care, and discuss how these variations can affect maternal health outcomes across different states. Let’s get started by understanding the basics of Medicaid managed care and why kick payments are essential.

Detailed Story

What is Medicaid Managed Care?

Medicaid managed care (MMC) involves states contracting with private health insurers to provide Medicaid coverage. This model covers about 70% of pregnant Medicaid enrollees and finances approximately 41% of all births in the United States. Under MMC, insurers receive per-member-per-month capitated payments to cover a defined set of benefits. However, covering pregnant individuals poses a higher financial risk due to their increased healthcare needs, which often leads to states implementing one-time “kick payments” to MMC plans triggered by delivery events.

The Role and Variation of Kick Payments

Kick payments are designed to offset the higher costs associated with childbirth. The rates and use of these payments can significantly influence whether MMC plans are incentivized to attract or avoid pregnant enrollees. This study aimed to assess the prevalence and magnitude of these kick payments across different states and how they align with actual delivery costs.

Research Methodology

The researchers conducted a cross-sectional study, abstracting data from state documents and MMC contracts published between 2018 and 2020. They gathered information on whether states used kick payments, the services covered by these payments, and the specific rates.

Additionally, they compared these rates with average state Medicaid fee-for-service (FFS) payments for delivery hospitalizations in 2020 and the Medicaid-Medicare fee index.

Key Findings

The study revealed that out of the 38 states and the District of Columbia using comprehensive MMC, 33 states used maternity kick payments. These payments varied significantly, ranging from $2,838 in New Hampshire to $14,493 in Maryland. Interestingly, the variation in kick payment rates did not correlate with the Medicaid payments to physicians or the actual delivery costs, indicating that in some states, kick payments might exceed delivery costs, while in others, they fall short.

These payments varied significantly, ranging from $2,838 in New Hampshire to $14,493 in Maryland.

Expert Insights

To further explore the implications of these findings, let’s delve into some expert insights.

Potential Implications of Low Kick Payment Rates

When kick payment rates are set too low, MMC plans might attempt to limit services for pregnant enrollees or restrict access to maternity care providers. This can lead to disparities in care quality and access, particularly affecting Black and Indigenous women, who are disproportionately enrolled in Medicaid and face higher risks of maternal mortality and morbidity.

The Need for Aligned Incentives

Aligning kick payment rates with actual delivery costs and care quality is crucial. States need to design Medicaid payment policies that support maternal health and promote health equity. This requires continuous research to understand the effects of these payments on care access, quality, and outcomes.

In-Depth Analysis

The Study’s Limitations

While the study provides valuable insights, it has some limitations. It could not directly associate kick payment rates with MMC plan behavior or maternal health outcomes. Additionally, the comparison was made with Medicaid FFS payments rather than the prices MMC plans paid for delivery services, which were unavailable.

The Path Forward

Further research is essential to evaluate the impact of kick payments on maternal care access and outcomes. Policymakers need comprehensive data to design effective Medicaid payment strategies that ensure equitable and high-quality maternal care.

Practical Tips

For state policymakers and healthcare administrators:

  1. Regular Review of Kick Payment Rates: Ensure that kick payment rates are regularly reviewed and adjusted to reflect actual delivery costs and care quality needs.
  2. Focus on Health Equity: Design payment policies that address disparities in maternal health outcomes, particularly for vulnerable populations.
  3. Data-Driven Decision Making: Use comprehensive data to evaluate the impact of payment policies on maternal care access and outcomes.

FAQ Section

Q1: What are Medicaid managed care kick payments? A: Kick payments are one-time payments made to Medicaid managed care plans to offset the higher costs associated with childbirth.

Q2: Why do kick payment rates vary between states? A: The variation can be due to different state policies, healthcare costs, and the structure of Medicaid managed care contracts.

Q3: How can low kick payment rates affect maternity care? A: Low rates can lead to MMC plans limiting services for pregnant enrollees or restricting access to maternity care providers, affecting care quality and access.

Q4: What can states do to improve kick payment policies? A: States should regularly review and adjust kick payment rates, focus on health equity, and use data-driven approaches to design effective payment policies.

Source

State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care

Dashboards: Breastfeeding Intention and Duration Indicators

The Breastfeeding Intention and Duration Indicators are key measures used to track breastfeeding practices and intentions among new mothers. These indicators include plans to breastfeed exclusively or in combination with formula, actual breastfeeding activities, and breastfeeding duration up to three months. They exclude mothers whose infants were not living with them at the survey time, ensuring data accuracy. These indicators help shape effective breastfeeding support programs, inform policy decisions.

Introduction

Breastfeeding is a critical component of infant health, providing essential nutrients and antibodies that help protect against infections and diseases. To monitor and improve breastfeeding practices, it’s essential to have accurate indicators that reflect breastfeeding intentions and behaviors. This blog post delves into key breastfeeding indicators, defining terms and outlining the criteria for inclusion and exclusion in related data surveys.

Breastfeeding Intention and Duration Indicators

1. Intended to Breastfeed

This indicator captures the mother’s or parent’s plan before delivery regarding breastfeeding. Specifically, it includes those who planned to either exclusively breastfeed or combine breastfeeding with formula feeding. It’s important to note that mothers or parents whose infants did not reside with them at the time of the survey are excluded from the denominator. This exclusion ensures that the data reflects the intentions of those who were in a position to breastfeed their child.

2. Intended to Breastfeed Exclusively

This indicator focuses on the mother’s or parent’s plan to exclusively breastfeed before delivery, without the use of formula or other supplements. Similar to the previous indicator, mothers or parents whose infants did not reside with them at the time of the survey are excluded from the denominator. This approach helps in accurately assessing the intention to exclusively breastfeed among those who had the opportunity to do so.

3. Ever Breastfed

The “ever breastfed” indicator refers to any instance of breastfeeding or feeding of breast milk by the mother or parent since the birth of the child. This broad indicator captures any initial breastfeeding activity and excludes mothers or parents whose infants did not reside with them at the time of the survey. By doing so, it ensures that the data accurately represents those who had the chance to initiate breastfeeding.

4. Any Breastfeeding at 3 Months

This indicator measures the extent to which infants are fed breast milk for at least three months after delivery. It includes both exclusive breastfeeding and breastfeeding combined with formula, other liquids, or food. The infant’s age is calculated from the date of birth on the birth certificate. Mothers or parents whose infants did not reside with them or whose infants were not yet three months old at the time the survey was completed are excluded from the denominator. This exclusion helps maintain the relevance and accuracy of the data by focusing on those who reached the three-month milestone.

Importance of Accurate Indicators

Accurate breastfeeding indicators are crucial for several reasons:

  1. Policy and Program Development: Reliable data helps policymakers and healthcare providers develop targeted programs to support breastfeeding mothers and improve breastfeeding rates.
  2. Resource Allocation: Understanding breastfeeding intentions and behaviors allows for better allocation of resources, ensuring that support systems are in place where they are most needed.
  3. Public Health Insights: These indicators provide valuable insights into public health trends, enabling better planning and intervention strategies to promote infant health and well-being.

Conclusion

Breastfeeding indicators play a vital role in understanding and improving breastfeeding practices. By clearly defining terms and carefully excluding certain groups from the denominator, these indicators provide accurate and meaningful data. This data, in turn, supports efforts to promote breastfeeding, contributing to better health outcomes for both mothers and infants. As we continue to monitor and analyze breastfeeding trends, we can work towards creating a more supportive environment for breastfeeding families.

Access: Breastfeeding Intention and Duration

Breastfeeding Intention and Duration Indicators

Intended to Breastfeed: This indicator measures the mother’s or parent’s plan before delivery to either exclusively breastfeed or to combine breastfeeding with formula. Excluded from this measure are mothers/parents whose infants did not reside with them at the time of the survey.


Intended to Breastfeed Exclusively: This captures the mother’s or parent’s pre-delivery plan to solely breastfeed without any formula or supplements. Mothers/parents whose infants were not living with them at the time of the survey are excluded.


Ever Breastfed: This indicator reflects any instance of breastfeeding or feeding of breast milk by the mother/parent since the birth of the infant. It excludes mothers/parents whose infants did not reside with them at the time of the survey.


Any Breastfeeding at 3 Months: This measure looks at whether the mother/parent fed their infant breast milk for at least three months after delivery, with or without supplementing with formula, other liquids, or food. Infants not yet three months old or not residing with their mother/parent at the time of the survey are excluded.


Importance of These Indicators
These breastfeeding indicators are crucial for developing support programs, informing policy decisions, and enhancing public health initiatives. They provide accurate insights into breastfeeding behaviors and intentions, helping to promote better health outcomes for both mothers and infants.

Decoding Healthcare Options: A Comparative Guide to ACOs, HMOs, and PPOs

This comprehensive guide offers an in-depth comparison of Accountable Care Organizations (ACOs), Health Maintenance Organizations (HMOs), and Preferred Provider Organizations (PPOs), three prominent healthcare models in the United States. It breaks down the fundamental differences and similarities across various dimensions, including network structure, patient choice and access to care, payment models, and their overall focus. Whether you’re a healthcare professional seeking clarity on these models or a patient navigating your healthcare options, this guide provides essential insights to understand how each model impacts care delivery, cost, and patient experience. By elucidating the complex landscape of healthcare options, this article empowers readers to make informed decisions about their healthcare needs, contributing to better health outcomes and satisfaction. Perfect for individuals looking to demystify healthcare terminologies and structures, our guide simplifies the decision-making process in choosing the right healthcare plan.

Given the popularity of this topic, we are publishing a table below presenting a comparison between ACOs, HMOs, and PPOs in a table format that can help readers quickly grasp the differences and similarities.

Navigating the landscape of healthcare options can be a daunting task for patients and providers alike. Among the plethora of models available, Accountable Care Organizations (ACOs), Health Maintenance Organizations (HMOs), and Preferred Provider Organizations (PPOs) stand out as prominent frameworks designed to streamline care delivery, manage costs, and improve patient outcomes. Each model boasts its unique structure and operational philosophy, catering to diverse healthcare needs and preferences. This blog post delves into the core characteristics of ACOs, HMOs, and PPOs, shedding light on their network structures, patient choice, access to care, and payment models.

At the heart of ACOs is a commitment to coordinated care, aiming to ensure that patients, especially the chronically ill, get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors. Unlike ACOs, HMOs emphasize preventive care within a closed network of providers, requiring patients to choose a primary care physician who oversees their health journey and referrals. On the other hand, PPOs offer a balance between flexibility and cost, providing patients the freedom to visit any healthcare provider, albeit at varying costs based on network status.

Understanding these differences is crucial for making informed healthcare decisions. Whether you’re a patient evaluating your healthcare plan options, a provider considering joining a healthcare network, or a policymaker analyzing healthcare system improvements, grasping the nuances of ACOs, HMOs, and PPOs can empower you to navigate the healthcare ecosystem more effectively. This comparison aims to illuminate the paths available for achieving high-quality, cost-effective care tailored to individual health needs.

FeatureACO (Accountable Care Organization)HMO (Health Maintenance Organization)PPO (Preferred Provider Organization)
Network StructureSelf-defined network of clinicians.Network defined by the health plan. Patients choose a primary care physician who acts as a gatekeeper.Network defined by the health plan. More flexibility to see specialists without a referral.
Patient Choice and Access to CarePatients cannot be limited to using only ACO clinicians. Freedom to see any clinician.Requires seeing clinicians within the HMO network. Primary care physician referral needed for specialists.Can use clinicians inside and outside the network. No referral needed for specialists, but higher cost for out-of-network services.
Payment ModelFee-for-service payments, with potential for shared savings. No change to underlying fee-for-service structure for clinicians.Capitation model where a clinician group receives a set amount per patient, incentivizing efficient care within the budget.Fee-for-service basis within the network. Different rates for out-of-network services, without primarily using capitation.
FocusImproving care coordination and quality while controlling costs.Cost control, preventive care, and efficiency within a closed network.Flexibility in provider choice with a broader network, offering a balance between cost and access to care.

Medi-Cal Managed Care Quality Improvement Reports (CA)

Various reports from the State of California regarding the quality of care provided by Medi-Cal managed care health plans. Plan-specific evaluation reports are also prepared for each individual health plan reviewed.

The California Department of Health Care Services contracts with an external quality review organization to evaluate the care provided to Medi-Cal managed care beneficiaries in the areas of quality, access, and timeliness. Reports are available on the DHCS website, including member satisfaction surveys, encounter data validation study reports, managed care accountability sets, external quality review technical reports, plan-specific evaluation reports, health disparity reports, HEDIS® reports, MCP-specific performance evaluation reports, performance improvement project reports, and preventive services reports.

Outline

  • Introduction: Purpose of the DHCS external quality review organization
  • Available Reports:
    • Member Satisfaction Surveys
    • Encounter Data Validation Study Reports
    • Managed Care Accountability Sets/External Accountability Sets
    • External Quality Review Technical Reports and Plan-Specific Evaluation Reports
    • Health Disparity Reports
    • HEDIS® Reports
    • MCP-Specific Performance Evaluation Reports
    • Performance Improvement Project Reports
    • Preventive Services Report
  • Conclusion: Summary of available reports and their purpose.

In accordance with federal requirements, the California Department of Health Care Services (DHCS) contracts with an external quality review organization (EQRO) to conduct external quality reviews and evaluate the care provided to beneficiaries by Medi-Cal managed care health plans (MCPs) in the areas of quality, access, and timeliness. The EQRO presents these external quality review activities, results, and assessments in reports that help DHCS and Medi-Cal MCPs understand where to focus resources to further improve the quality of care.

Medi-Cal Managed Care Quality Strategy Reports

The Medi-Cal Managed Care Quality Strategy Reports are DHCS’ written strategy for assessing and improving the quality of managed care services offered by all Medi-Cal MCPs.

Member Satisfaction Surveys (CAHPS® Surveys)

Each Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey report aggregates the results of CAHPS® surveys, which ask Medi-Cal managed care beneficiaries to evaluate their experiences with their health care health care providers.

Encounter Data Validation Study Reports

Encounter Data Validation (EDV) Study Reports examine the completeness and accuracy of the encounter data submitted to DHCS by the MCPs.

Managed Care Accountability Sets / External Accountability Sets

The Managed Care Accountability Sets (MCAS) / External Accountability Set (EAS) is a set of performance measures that DHCS selects for annual reporting by Medi-Cal MCPs.

External Quality Review Technical Reports and Plan-Specific Evaluation Reports

The EQRO annually prepares an independent external quality review technical report that analyzes and evaluates aggregated information on the health care services provided by Medi-Cal MCPs. As part of the external quality review technical report, the EQRO prepares a plan-specific evaluation report of each of MCP.

Access these reports on the Medi-Cal Managed Care External Quality Review Technical Reports with Plan-Specific Evaluation Reports.

Health Disparity Reports

The Health Disparity Reports identify and understand health disparities affecting California’s Medi-Cal managed care members and are based on focused studies conducted annually by the EQRO. The reports analyze Managed Care Accountability Set (MCAS) measure results reported by Medi-Cal managed care plans (MCPs) for various demographic categories.

HEDIS® Reports

The Healthcare Effectiveness Data and Information Set (HEDIS®) Aggregate Report, also referred to as Performance Measurement Reports, provides performance rates of MCPs during a reporting year and trending using previous years’ data. The report also compares plan-specific and aggregated rates to national benchmarks.

MCP-Specific Performance Evaluation Reports

The MCP-Specific Performance Evaluation Reports are also referred to as Plan-Specific Performance Evaluation Reports.

Access these reports on the Medi-Cal Managed Care Quality Improvement Reports webpage

Performance Measures and HEDIS® Reports

Access Medi-Cal Managed Care’s annual performance measure, External Accountability Set, on the Medi-Cal Managed Care Quality Improvement Reports webpage.

The following performance measure results are also available on our website:

Performance Improvement Project Reports

Plan-Specific Performance Evaluation Reports

Plan-Specific Performance Evaluation Reports are also referred to as MCP-Specific Performance Evaluation Reports.

Access the reports on the  Medi-Cal Managed Care Quality Improvement Reports: External Quality Review Technical Reports and Plan-Specific Evaluation Reports.

Quality Improvement Project Reports

Quality Improvement Project (QIP) Reports are available on the Medi-Cal Managed Care Quality Improvement Reports: Quality Improvement Project Reports webpage.

Technical Reports

Technical Reports are available on the Medi-Cal Managed Care Quality Improvement Reports: External Quality Review Technical Reports webpage.

Preventive Services Report

The 2021 Preventive Services Report and Executive Summary assist with identifying and monitoring appropriate utilization of preventive services for children in Medi-Cal Managed Care.

The 2020 Preventive Services Report and Addendum assesses the provision of preventive services by pediatric Medi-Cal managed care members.

Physician-Employer Engagement: “Direct-to-Employer” Arrangements

Physician-Employer Engagement has become a popular method for physicians to provide healthcare services to employees of companies. This approach is often referred to as “Direct-to-Employer” arrangements.

Physician-Employer Engagement has become a popular method for physicians to provide healthcare services to employees of companies. This approach is often referred to as “Direct-to-Employer” arrangements.

Physician-Employer Engagement: “Direct-to-Employer” Arrangements

Introduction

Physician-Employer Engagement, also known as “Direct-to-Employer” arrangements, has become a popular method for physicians to provide healthcare services to employees of companies. This approach allows physicians to work directly with employers to provide healthcare services to employees, rather than through traditional insurance reimbursement models. In this blog post, we will discuss the benefits of Direct-to-Employer arrangements and what to consider before entering into such a contract.

Benefits of Direct-to-Employer Arrangements

One of the main benefits of Direct-to-Employer arrangements is the ability to offer more personalized and accessible healthcare services to employees. These arrangements often include on-site clinics, telemedicine services, and wellness programs that can be tailored to the specific needs of the company’s workforce. This can lead to increased productivity, reduced absenteeism, and improved employee satisfaction.

Another benefit of Direct-to-Employer arrangements is the potential for cost savings. By working directly with employers, physicians can negotiate pricing and services that are tailored to the needs of the company. This can lead to lower healthcare costs for both the employer and the employee.

Considerations Before Entering into a Direct-to-Employer Arrangement

Before entering into a Direct-to-Employer arrangement, it is important to consider several factors. First, it is important to understand the legal requirements and regulations related to providing healthcare services directly to employers. This includes understanding state and federal laws related to licensure, insurance, and privacy.

Financial considerations are also important to keep in mind. Physicians should understand the costs associated with setting up and maintaining an on-site clinic or telemedicine service, as well as the potential revenue streams and payment models.

Finally, operational logistics should be carefully considered. Physicians should ensure that they have the necessary staffing, equipment, and technology to provide high-quality healthcare services to employees. They should also consider how they will communicate with the company’s human resources department and how they will manage patient records and data.

Conclusion

Physician-Employer Engagement, or Direct-to-Employer arrangements, offer several benefits to both physicians and employers. By providing personalized and accessible healthcare services to employees, physicians can help improve productivity, reduce absenteeism, and increase employee satisfaction. However, it is important to carefully consider the legal, financial, and operational logistics before entering into such a contract. By doing so, physicians can ensure that they are providing high-quality healthcare services while also maintaining a profitable practice.

If you are interested in learning more about this type of engagement, check out this checklist provided by the American Medical Association. The checklist covers important aspects such as legal requirements, financial considerations, and operational logistics. It is important to have a comprehensive understanding of Direct-to-Employer arrangements before entering into such a contract.

Healt Plan Leaders’ Statements About VBC

“The patient-centered medical home has served as a catalyst and organizing philosophy to refine our state care delivery system. It has brought stakeholders from both the public and private sector together to organize around a philosophy of care delivery that brings value to our citizens. This model serves to create value in our health care system through improving the quality of care delivered to patients and maximizing the value of each health care dollar spent.”

Health Plans

“The patient-centered medical home has served as a catalyst and organizing philosophy to refine our state care delivery system. It has brought stakeholders from both the public and private sector together to organize around a philosophy of care delivery that brings value to our citizens. This model serves to create value in our health care system through improving the quality of care delivered to patients and maximizing the value of each health care dollar spent.”

–Julie Schilz, R.N., B.S.N., IPIP, Director, Patient Centered Care, Wellpoint

“The patient-centered medical home encourages strong, meaningful relationships among families, their physicians and care teams, and their health plans. The result is care that is accessible, continuous, and compassionate with care deliverers and patients working together. In this model, patients are better empowered and ultimately can make more informed health care decisions for themselves and their families. The patient-centered medical home is a core tenet in ‘The Pathway to Covering America,’ the Blue Cross and Blue Shield recommendations to Congress and the American people for a better health care system for the future.”

–Scott P. Serota, President and CEO, Blue Cross and Blue Shield Association

“The patient-centered medical home represents a pro-active approach to guiding patients as they take a more active role in managing their own health and medical conditions. Creating a health care team with the patient at the center involves many challenges ranging from enhanced information support at the time of service to improving communication and educational skills.”

 –Thomas Simmer, M.D., Senior Vice President and Chief Medical Officer, Blue Cross Blue Shield of Michigan

“We believe the patient-centered medical home model is a promising approach that facilitates moving from a fragmented health care system to a more coordinated system, improving satisfaction for our customers and their primary care providers.”

–Jeff Kang, MD, MPH, Senior Vice President & Wellness Services, Walgreens

Changing Demographics & Value-Based Care

 

Changing Demographics & Value Based Care

The U.S. is stuck in a system of volume-based (fee-for-service) care that continues to drive up costs without providing better outcomes for patients. At a time when so many Americans and employers are looking for new solutions to high prices and poor health outcomes, value-based care can slow the trajectory of costs. Instead of clinicians charging patients and insurers for every appointment, test, or service, value-based payment approaches provide clinicians with more flexibility and accountability to focus on meaningful, cost-effective services to improve their patients’ overall health. Opportunities for success include fewer visits to the doctors’ office, fewer trips to the emergency room, and ultimately the elimination of avoidable hospitalizations.

The United States is going through a fundamental shift in its demographics. By 2035, there will be more seniors than children under the age of 18. This comes as the number of clinicians and caregivers for those seniors is decreasing rapidly, putting pressure on healthcare and social service systems to improve the efficiency of how they care for our nation’s seniors.

Telehealth and connected care have the potential to increase the reach of the healthcare system where seniors want to receive care. Regardless of reimbursement and incentives, connected care and telehealth are essential for any healthcare system to adapt to our nation’s changing demographics and provide care that helps seniors age-in-place.

The United States is going through a fundamental shift in its demographics. By 2035, there will be more seniors than children under the age of 18. This comes as the number of clinicians and caregivers for those seniors is decreasing rapidly, putting pressure on healthcare and social service systems to improve the efficiency of how they care for our nation’s seniors.

Telehealth and connected care have the potential to increase the reach of the healthcare system where seniors want to receive care. Regardless of reimbursement and incentives, connected care and telehealth are essential for any healthcare system to adapt to our nation’s changing demographics and provide care that helps seniors age-in-place.