Unbiased Analysis of Today's Healthcare Issues
A paper by Mark Shepard and Jacob Wallace (2026) has a great overview of the Medicaid managed care program. The first question one may have is, how does Medicaid managed care differ from other forms of government procurement. “In standard public procurement—such as contracting for infrastructure projects—the government specifies desired services, solicits bids, selects winners,…
Let’s say you’re the CEO of a health plan. A new drug just received approval to treat patients with lung cancer. The drug’s clinical trial examined how well the the drug worked on third line (3L) patients and patients with good funcional ability (e.g., performance status ECOG score of 0 or 1). FDA approved the…
The Peterson Health Technology Institute (PHTI) recently released a report titled: “Administrative AI: Current Use and Potential Impact.” The report was based on a workshop PHTI convened with senior leaders from health systems, health plans, technology developers, investment firms, and federal agencies in order to discuss how technology and policy can enable AI to reduce…
Medicare Advantage (MA) plans have a number of advantages and drawbacks over traditional Medicare (TM) (i.e., fee-for-service). One advantage of MA plans is that cost sharing is often lower. Another benefit is that enrollees may receive additional coverage benefits. One drawback is that enrollee provider choice may be restricted. Fewer provider options may be bad…
A CMS proposed rule would expedite the prior authorization approval process. CMS summarizes key provisions of the rule as follows: Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason…
In 2020, spending on specialty drugs was $265 billion; this constituted 49.6% of total prescription drug expenditure. To combat rising costs, payers have turned to white, brown and clear bagging as well as approaches to restrict the site of care where patients receive specialty drugs. What are these “bagging” policies, what are the pros and…
According to a recent paper by Wallace (2023), the answer is ‘yes’, but it does so in a highly inefficient manner. Using 2008-2012 Medicaid data from the New York State Department of Health, the author find that: Leveraging the random assignment of over 50,000 Medicaid enrollees in New York, I present causal evidence that narrower…
Are narrow networks a good thing or a bad thing? The first thing you need to know is what is a “narrow network”. Narrow networks is an informal terms which basically means that your health plan either places restrictions over the providers you are able to see and/or you certain providers that are out of…
Managed care, as the names suggests, aims to manage health care. The goal is to identify high quality, low cost treatments in order to insure that patients get the best care while keeping premiums low. While good in theory, managed care critics often contend that some of the stricter managed care policies reduce patient access…
How will Medicaid expansions affect patient access to pharamceuticals? This question is particularly relevant for patients with serious mental illness. The answer is complicated by the increasing presence of Medicaid managed care plans. Increasingly, states have turned to contracts with Medicaid managed care plans in order to better control costs and reduce budgetary uncertainty. However, in…