As we noted in July, CMS declined Massachusetts’ Medicaid 1115 demonstration request to establish a closed formulary.  The proposed program would have given Massachusetts the ability to exclude certain FDA-approved drugs from coverage and thereby given the state additional leverage in negotiating rebates.  The state and drug manufacturers would have otherwise continued to be subject to the rest of … Read more

As the United States continues to move toward a value-based health care system, significant challenges slow down our progress. Political pressure exists from all sides, incentives have yet to be appropriately aligned, and the pressing need to change stakeholder behavior remains a time-sensitive imperative. Solving these challenges requires going beyond admiring the challenges to implementing … Read more

According to the National Institute on Drug Abuse and the CDC, in 2015 over 33,000 people died from opioid overdose in the United States, and in 2013 prescription opioid abuse cost the U.S. economy approximately $78.5 billion in costs related to health care, crime, and loss of productivity. Opioid abuse and the related overdose deaths are harming individuals, families, the … Read more

In the U.S., a person’s health status is impacted by a variety of factors such as race/ethnicity, disability status, socioeconomic status, age, gender, sexual orientation, geography, and more. These differences in society are linked to inequalities in health status that are referred to as health care disparities. The CDC defines health disparities as “preventable differences in the … Read more

Micro-Hospitals Defined While the health care industry continues to shift from volume to value, costs of inpatient care continue to rise, averaging $2,346 per inpatient per day. Consequently, payers and providers are seeking new ways to reduce hospital length of stay (LOS) and deliver care at less costly locations. One such mechanism is the emerging trend … Read more

Background The Quality Payment Program (QPP) under MACRA is now more than three months underway into the first payment year. However, there are still many nuances of the program, specifically under the multi-payer Advanced APM option, that payers —including commercial, Medicare Advantage, and Medicaid — and clinicians need to understand before they can begin collaborating, … Read more

The Affordable Care Act turned Medicaid into America’s largest public health care coverage program. While the volume associated with this growing program created increasing opportunities for providers, health systems, health plans, and vendors, these same stakeholders shouldn’t write off opportunities in Medicaid now simply because of the change in direction at the federal level. Instead, … Read more