The line between inpatient admission and observation care is one of the most consequential decisions in hospital medicine. For payers, it sits at the center of medical necessity disputes, length-of-stay variability and post-payment audit risk. This white paper walks through…
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Cancer outcomes have improved but delays and fragmentation still define much of the care journey. Patients wait an average of 156 days between screening and diagnosis, and every four-week delay can increase mortality risk by 6 to 8 percent. For…
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Tens of millions of average-risk adults remain overdue for colorectal cancer screening, even as colorectal cancer has become the leading cause of cancer death among Americans under 50. Traditional mailed FIT programs often struggle to sustain engagement, complete follow-up colonoscopy…
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Most payer organizations agree AI will reshape underwriting, claims and operations. But many initiatives still struggle to move beyond isolated pilots. The challenge is no longer whether AI matters. It’s how to operationalize it responsibly. This new white paper examines…
Members with serious illness often experience fragmented care, avoidable hospitalizations and repeated emergency department visits before receiving meaningful support. For health plans, the result is rising utilization, higher costs and growing pressure to improve quality performance across Medicare, Medicaid and…
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2026 marks an unprecedented convergence of forces that will reshape the market landscape: This executive brief reveals why traditional gap closure programs are failing and how diagnostic intelligence enables the shift from retrospective campaigns to continuous, real-time quality management. Healthcare…
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The payer business model built for the last twenty years can’t carry the next ten. At Becker’s Spring Payer Issues Roundtable, the leaders running health plans at Humana, Kaiser Permanente, Blue Shield of California, Elevance Health, Highmark, Oscar Health and…
Consumer demand for virtual care continues to grow — and expectations are expanding beyond episodic care. New research shows insured adults are increasingly open to using virtual care across a broader range of needs, yet real‑world use has not fully…
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Musculoskeletal conditions are among the largest cost drivers for Medicare Advantage plans. As populations age, surgical interventions and downstream utilization continue to drive spending — even when conservative care options may be appropriate. A new analysis of Medicare Advantage members…
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Today’s Medicare Advantage payers are navigating rising enrollment, changing HCC models and heightened audit scrutiny from CMS. At the same time, quality standards continue to tighten, putting Star Ratings and revenue at risk when documentation and coding fall short. This…
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