Cost of Care
Expert articles and analysis related to cost of care.
AI Summary — Last 30 Days
CMS and DOJ activity is intensifying pressure on Medicare Advantage–enabled VBC models to prove that risk adjustment reflects real clinical acuity rather than coding arbitrage, with recent False Claims Act settlements involving Complete Health and Humana-owned The Villages Health signaling a higher-cost compliance environment for primary care platforms, MA plans, and delegated-risk groups. At the same time, CMS is tightening plan operations through prior authorization transparency requirements and broader payment-model movement—including mandatory total joint replacement bundling—pushing providers and payers to pair utilization management, documentation integrity, and care redesign more tightly. For ACOs and VBC operators, the strategic tension is clear: growth in capitated and delegated models remains attractive, but cost-of-care performance will increasingly be judged against auditability, coding discipline, and measurable reductions in avoidable utilization rather than revenue optimization alone (Complete Health settlement; Villages Health settlement).
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