CMS and AHIP are raising the floor, but forward-thinking plans are aiming higher. They’re designing utilization management systems that are clinically sound, operationally efficient, and aligned with enterprise goals.
These updated guidelines are a good opportunity for SNFs to change how they operate moving forward. Those who start implementing new policies and objectives soon and begin to operate as one system, rather than prioritizing each outcome separately, will be the ones to see the greatest results.
How Apella leverages technology to increase OR efficiency.
Care pathways are, in essence, the maps we follow to get patients from where they are to where they want to be. However, many rehab care plans are still too fragmented, too reactive, and too disconnected from the broader ecosystem of care. This won’t cut it in this next phase of transformation.
CMS’ new $50 billion rural health fund seeks to help rural providers sustain care in their communities over the next five years. However, experts believe the program will not be enough to stabilize the finances of rural hospitals — especially in the face of worsening reimbursement issues, an ongoing workforce crisis and billions of dollars’ worth of Medicaid cuts on the horizon.
CMS Administrator Dr. Mehmet Oz said that Medicaid’s rapid spending growth is unsustainable and criticized state financing tactics that let providers and governments “game” the system for extra federal funds. He said CMS is shifting its fraud strategy to follow the flow of money rather than just individual offenders in an effort to ensure health dollars are used for legitimate care.
Experts believe value-based care won’t ever reach scale unless fundamental barriers are addressed — including voluntary models, misaligned payer incentives, excessive metrics and weak employer engagement.
Solera Health is working to streamline employer contracting with health tech.
As an industry, we need to ask hard questions. Are delegated vendors delivering on the promise of better, faster, more transparent decisions? Or are they simply moving the pain to another part of the system?
Healthcare groups are pushing back on CMS’ proposed physician fee schedule for next year, raising concerns over payment cuts, administrative burdens and mandatory participation in a new value-based model. Organizations including MGMA, NAACOS and Premier are calling on the agency to revise its plan.
Out of the 476 ACOs that participated in the Medicare Shared Savings Program in 2024, 75% earned $4.1 billion in performance payments, CMS reported.
This proposal reflects a broader shift toward more restrictive oversight of inpatient utilization. As CMS finalizes this policy, providers should be aware of the immediate compliance and reimbursement risks associated with the phase-out.
Across the nation, state-based health insurance exchanges are searching for ways to better serve their communities while making enrollment easier, more personal, and more accessible for everyone.
Health care in the United States is confusing for patients and consumers. Price transparency is a step in the right direction — transformative change can happen by combining cost, quality, appropriateness and efficiency measures.
A combined bottom-up facility-level approach to integrated data and a top-down national-level effort for connected networks is needed to eliminate data silos and deliver frictionless care.
Outcomes are no longer a nice-to-have or a post-hoc justification for care provided. They are a central currency of care in a system that’s shifting faster than ever toward accountability.
CMS launched a new initiative to promote better data interoperability and digital health innovation. As part of the effort, more than 60 organizations pledged to build patient-facing apps and support secure data sharing — including OpenAI, Amazon, Apple, Cleveland Clinic and Providence.
High-performing groups treat utilization with the same rigor they apply to coding and quality. Here are four key principles we’ve seen successful organizations adopt.