Recent trends are affecting providers’ revenue cycles and altering how providers should manage those cycles. Basic RCM is no longer enough.
Enrollment in the individual market decreased by about 2 million members between Q1 2016 and Q1 2017. However, membership changes differed considerably between the on-exchange and off-exchange markets, and between carrier types.
The US health insurance industry continues to be defined by uncertainty. The 25 articles in this compendium can help health insurers navigate the changes ahead.
An analysis of the individual market health plans being offered across the U.S.reveals that the trends toward narrowed hospital networks and managed care continue.
A new concept, organizational agility, can help healthcare companies adapt more quickly to changing customer needs, competitor responses, and regulatory guidelines—without requiring a full-scale restructuring.
In our healthcare system, those in the best position to control risks and costs often have inadequate incentive to do so. Refining healthcare financing and reimbursement requires a deep understanding of the nature of medical risk.
M&A remains an important option for health systems, but targets and strategies are shifting. While traditional economies of scale will continue to be a strong stimulus for M&A, providers will likely seek and achieve value creation much differently in the future.
Traditional arguments for EHR implementation such as efficiency gains and meaningful-use incentives are insufficient to maximize a health system’s returns on its technology investments. However, clinically and operationally oriented sources of value can generate an additional $10,000 to $20,000 per bed in annual margin.
Consumers’ accountability for healthcare spending is increasing, and more than a thousand companies are developing new digital/mobile technologies that should allow consumers to take greater control over their healthcare choices. This combination may disrupt the industry’s migration toward larger, more integrated systems and put almost $300 billion—primarily, incumbent revenues—into play.
What states, private payors, providers, and technology companies are doing to control costs and improve outcomes for individuals with behavioral health conditions or in need of long-term services and support, including those with intellectual or developmental needs.
Although structurally simple to create, clinically integrated networks (CINs) are difficult to get right. Health systems considering establishing CINs must think through what it truly takes to create value through these entities and then make sure they have designed the CINs appropriately.
Offering a health plan can give health systems an opportunity for growth, but it is not without financial risk. To benefit from this move, health systems should use a different lens to understand both consumers and risk, know where the best growth opportunities are, rethink their payor-provider interactions, and take advantage of integrated claims and clinical data.
Faced with increasing challenges to their business model, many academic medical centers (AMCs) are seeking new sources of financial and competitive advantage, including partnerships with community health systems. These arrangements can be difficult to structure, but eight lessons can help AMCs avoid pitfalls and maximize the odds of success.
The potential of digitization is well understood, yet healthcare systems are struggling to convert ambition into reality. Here’s what we recommend.
As consumers take an increasingly active role in healthcare decision making, payors and providers need an accurate understanding of how healthcare consumerism is playing out. Using data from surveys of thousands of people across the U.S., we debunk eight of the most common myths circulating in the industry.
The newer approaches to managing oncology care have been somewhat effective in controlling near-term costs, but are often cumbersome and create friction between stakeholders. A more integrated program, however, can deliver long-term benefits to both payors and providers.
A comprehensive approach health systems can use to better understand the patient experience and thereby improve patient satisfaction.
Updated 2015 network data, including a comparison of networks offered on the 2014 and 2015 exchanges, insights into how networks’ pricing structures are evolving, and insurer and provider participation.
Improving outpatient access can deliver a triple win for payors, providers, and patients.
By offering its own health plan, a hospital system may be able to gain a variety of advantages -- but the move is not without risks.
Our third intelligence brief on ACA exchange dynamics sets forth five observations based on analysis of new network configurations across 20 urban rating areas.
The trillion-dollar prize: Using outcomes-based payment to address the US healthcare financing crisis
There is growing consensus that transitioning to outcomes-based payment is fundamental to driving cost-reducing innovation among healthcare providers and achieving a financially sustainable healthcare system.
In the post-reform era, payors will attempt to capture savings by creating limited networks with reduced reimbursement rates. To respond, health systems need a clear understanding—market by market—of their competitive advantages and of when, if, and how to trade price for volume.
For most health systems, the one-time impact of expanded insurance coverage on utilization will be small but significant. Systems that can capture a substantial share of the increase in utilization may gain a competitive advantage.
This series of articles examines transformational imperatives specific to health systems in the post-reform era, drawing on extensive work with healthcare stakeholders across the value chain.
Health systems (and health plans) that are serious about transforming themselves must harness the energy of their physicians. To do so, they must develop a true ability to engage physicians effectively.
Given today’s realities, health systems must look beyond the traditional economies of scale if they want to reap the full benefits of M&A. They must consider other economies that M&A can offer, commit themselves fully to the effort, and execute flawlessly.
Operating margins at AMCs are under severe pressure, placing their tripartite mission at risk. To survive, AMCs need significant structural and cultural changes. Five steps are imperative if they are to navigate the challenges ahead.
A multiprong approach that puts physicians—and clinical care—at the heart of performance transformation efforts can help hospitals and health systems deliver more financially sustainable, patient-oriented, and physician-friendly care.
Although the ACA may make revenue cycle operations more complex, it also presents an opportunity for providers to improve, excel, and differentiate. By adapting their RCM operations and acquiring new capabilities, providers could open up opportunities to win.
Accounting for the cost of U.S. healthcare: Pre-reform trends and the impact of the recession (2011)
This report analyzes US healthcare spending trends overall and by category of care, and compares US healthcare expenditures with other developed countries.
Care pathways enable health systems (and other healthcare organizations) to make evidence-based decisions about where to focus improvement efforts.
Mandated upgrades to healthcare IT will demand heavy investments by providers but will help them minimize waste and standardize best medical practice.
Better procurement practices can help hospitals achieve rapid supply cost reductions of 20 percent or more and keep future cost escalations under control.
At the time of publication, the United States spent $650 billion more on healthcare than expected, even when adjusting for the economy’s relative wealth. This report examines the underlying trends and key drivers of these higher costs.
The United States spends more on healthcare than comparable countries do and more than its wealth would suggest. Here’s how—and why.
All signs point to a more specialized future for US hospitals. But getting from here to there won’t be easy.