Although end-to-end digital claims management is still a distant vision, much can be gained from digitizing portions of the claims process today.
Topic Payment & delivery innovation
Technology-driven innovation holds the potential to improve our understanding of patients, enable the delivery of more convenient, individualized care—and create $350 billion–$410 billion in annual value by 2025.
Addressing the social determinants of health: Capturing improved health outcomes and ROI for state Medicaid programs
The social determinants of health (SDoH) strongly contribute to variations in health status. Addressing SDoH can help ensure access to high-quality care, improve outcomes, and manage costs.
Value-based care models are becoming increasingly important for health systems. Implemented well, they can improve system economics, enhance care quality and outcomes, and strengthen physician alignment.
To aid APM (re)design and support providers and payers in their value-based contracting strategy, this paper highlights seven characteristics that distinguish well-performing APMs from poorly performing models.
Machine learning is transforming the healthcare industry by changing the way care is delivered, and its impact is poised to increase.
Extending the use of episode analytics beyond alternative payment models: A scalable architecture for improving payer performance
Payers (and providers) that have dismissed bundled payments or treated it as a narrow part of their strategies may under-appreciate the value of episode analytics in improving core business functions.
Ken Burdick, CEO, WellCare shares his perspective on major trends and opportunities in US healthcare with David Nuzum, Senior Partner, McKinsey and Company.
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.
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.
This paper explores opportunities states could consider to improve their Medicaid programs, both to control spending and improve the program's performance.
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.
Employers are showing increasing interest in new payment, delivery, and funding models. To capture the opportunity, payors must be able to target appropriate employers; educate employers, employees, and brokers; and demonstrate savings.
Four fundamental questions can help payors and providers improve productivity and better control utilization—the prerequisites for making value-based care sustainable.
A wide range of changes to stabilize the individual market have been proposed. This special report examines the impact some of the initiatives could have on claims costs and enrollment by the uninsured.
The findings in this Intelligence Brief provide an introductory perspective on how the next US administration and Congressional Republicans may approach altering the ACA and related legislation. The information is based on publicly reported information released through December 8, 2016. Our Reform Center team is continuing to refresh this perspective on a real-time basis and is closely analyzing potential implications and economic impacts for each policy element under a full range of scenarios.
Two steps—increasing healthcare-sector productivity and improving healthcare-market functioning to better balance the supply of and demand for health services—would likely produce sufficient savings to lower medical cost inflation to the rate of GDP growth.
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.
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.
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.
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.
Following the decision to become a value-based provider, how did the Emory Healthcare Network look to make transformation real?
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.
There is widespread agreement that if the United States is to achieve sustainable levels of health care spending, it must make greater use of payment mechanisms that reward physicians, hospitals, and health systems for the results achieved. The vexing question is how best to make this transition.
Many payors now have experience developing value networks, but they may not yet have optimized their network configuration or approach. Over the long term, payors must be able to maximize the value these networks deliver.
Big data could transform the healthcare sector, but the industry must undergo fundamental changes before stakeholders can capture its full value.
To address the rising cost of chronic conditions, health systems must find effective ways to get people to adopt healthier behaviors. A new person-centric approach to behavior change is likely to improve the odds of success.
Articles in this publication are designed to help payors, providers, and health systems overcome the challenges ahead and leverage integrated care effectively to deliver better patient care at a lower cost.
Care pathways enable health systems (and other healthcare organizations) to make evidence-based decisions about where to focus improvement efforts.
The development of an automated payment network would reduce bad debt, cut administrative costs, and save billions of dollars.
While pilots are underway and some progress is being made to restructure US healthcare payments, there is still much more to be done.
As American consumers shoulder more of the burden of healthcare costs, new models are needed to facilitate payment flows, combat growing bad debt, and improve efficiency across the value chain.
A hugely inefficient payment system is ripe for transformation. The inefficiency is concentrated in the $250B that consumers pay doctors and hospitals, and the $1.3T that insurers send to these providers.