Cost of Care Management
Expert articles and analysis related to cost of care management.
AI Summary — Last 30 Days
CMS under the Trump administration is tightening the cost-of-care agenda across Medicare Advantage and episode-based payment: the 2027 MA rate notice and RADV extrapolation posture are increasing pressure on plans’ coding-driven margins, while CJR-X and the forthcoming LEAD model reinforce the shift toward data-driven episode management, post-acute visibility, and avoidable utilization control. At the same time, Congress is scrutinizing CMS’s AI-enabled prior authorization pilot amid concerns about beneficiary access, underscoring a central VBC tension: using automation and utilization management to reduce waste without creating delays or denials that undermine care. For providers, ACOs, and payers, the strategic priority is moving from broad “risk readiness” to operational cost management—specialty integration, post-acute control, payer-provider clinical alignment, and defensible risk adjustment—especially as MA enrollment now covers 55% of eligible Medicare beneficiaries and payment scrutiny intensifies (HFMA on MA payment changes; Healthcare Dive on AI prior authorization pilot).
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