Health care leaders have long viewed fraud, waste, and abuse as compliance issues. But as more provider organizations accept financial risk through accountable care and other value-based arrangements, fraud, waste, and abuse are no longer simply compliance concerns. They are increasingly financial performance risks that can directly affect benchmark attainment, shared savings results, and care…
Sustainability has become less about cutting costs and more about redesigning how healthcare delivers value. Becker’s asked several health plan leaders how they’re thinking about long-term sustainability, and the responses point to a shared shift away from volume-driven models toward outcomes, accountability, and member-centered design. From shifting social health programs toward measurable, evidence-based interventions to redesigning the…
Download Slides CMS has doubled down on its commitment to reining in specialty costs by proposing another mandatory episode-based care model: Comprehensive Care for Joint Replacement Expanded, or “CJR-X.” Like the Transforming Episodic Payment Model (TEAM), CJR-X is focused on procedural episodes of care, but its global application and pinpoint focus will drastically impact…
In our last four articles, we have focused on payment models and infrastructure to establish how ACOs can be central to Value-Based Care, even under specialty models. Now it’s time to shift our focus back to what the payment models set out to do: improve patient health and rationalize costs. We cannot lift up patient…
Addressing Structural Challenges in the Business of Benefits Through AI Innovation Employer plans, whether self-funded under the Employee Retirement Income Security Act of 1974 (ERISA) or fully funded through a commercial plan, will likely have a proactive mindset that will lead to greater coverage modeling scenarios, plan accountability, and a focus on outcomes to successfully…
AI isn’t failing because it lacks capability. It’s failing because it isn’t consistently reaching the moments where decisions are made. Healthcare isn’t struggling to adopt AI. In fact, the industry has moved quickly from early experimentation to widespread investment in tools designed to improve clinical decision-making, reduce administrative burden, and drive financial performance. Many health…
Value-based care runs on a simple bet: an organization takes financial responsibility for a population’s health and keeps the savings if it can hold costs down. The organizations making that bet, physician-led IPAs, ACOs, Medicare Advantage groups, and the health plans they contract with, all run the same kind of back office to deliver on…
Why fragmented patient data became a financial and regulatory liability, and how clinical AI closes the gap at the point of care Healthcare’s data isn’t missing. It’s everywhere. We talk about value-based care like it’s a contracting problem. Get the attribution and quality measures right, and performance follows. But the real work of winning under…
To mark the 20th anniversary of value-based care, health care innovation and value-based care (VBC) leaders reflect on how the industry has evolved—and why success over the next 20 years will depend on moving from payment reform to the infrastructure, data, and care models needed to deliver measurable outcomes. Patty Hayward, General Manager of Health…
When physicians describe the forces reshaping medicine, they increasingly point not to a new device or a breakthrough drug but to the economics underneath their work. The move from fee-for-service to value-based payment is no longer theoretical. For a growing number of specialists, it is starting to feel personal. That change in perception is worth…