Cost Affordability Management
Expert articles and analysis related to cost affordability management.
AI Summary — Last 30 Days
Cost affordability management is shifting toward tighter scrutiny of whether “value-based” arrangements actually reduce avoidable utilization rather than simply repackage risk: HHS OIG findings that the largest Medicare Advantage insurers denied post-acute prior authorization requests at elevated rates are intensifying pressure on MA risk models, while Senate Democrats’ effort to roll back CMS’ WISeR AI prior authorization model underscores the political tension between utilization management, beneficiary access, and administrative automation. At the same time, specialty-focused VBC models are gaining strategic relevance, with Blue Cross NC’s Advanced Kidney Care program and Oshi Health’s GI model positioning outcomes-based specialty partnerships as a more targeted affordability lever for high-cost populations than broad risk transfer alone. For ACOs, payers, and health systems, the near-term playbook is becoming more granular: pair condition-specific risk alignment and data-driven episode management, such as CJR-X analytics, with stronger governance over prior authorization and access safeguards as MA penetration reaches 55% of eligible Medicare beneficiaries in 2026 (KFF MA trends; HHS OIG coverage via Healthcare Dive).
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Private insurance prices grew 47% faster than Medicare rates since 2019: 5 notes - beckerspayer.com
Private insurance prices grew 47% faster than Medicare rates since 2019: 5 notes beckerspayer.com