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Why the Best AI Won’t Win in Healthcare

  • Biopharma , 
  • Payers , 
  • Providers , 
  • Medtech , 
  • Digital
As advanced AI becomes widely accessible, healthcare companies can no longer rely on superior technology alone for lasting advantage. Instead, they need a coherent AI strategy built around five interconnected choices. Harvard Business Review article.

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Outcomes Based Arrangements in Biopharma

  • Biopharma , 
  • Payers , 
  • Institutional
Today’s advanced therapies target devastating diseases with high unmet need. Given the urgent medical need (and pressure from patient advocates), regulators increasingly must make decisions based on early, incomplete data when it comes to durability, real-world effectiveness, and cost-effectiveness – all while bearing costs that can exceed $1 million per patient.

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AJMC: More frequent visits to primary care can save net $30-40 PMPM for top 20% highest risk commercial members

  • Payers , 
  • Providers
A new AJMC study from consulting firm Recon Strategy is the first to s…

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Kidney transplantation, improved but still a significant missed opportunity

  • Payers , 
  • Providers , 
  • Institutional
In order to make a more immediate and significant impact on dialysis and kidney waitlist, OPOs need to ensure that significantly more potential donors are identified, and all necessary steps are taken to ensure that a potential donor becomes an actual organ donor.

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Are some of Kaiser’s regional ambitions starting to pay off?

  • Payers , 
  • Providers
PDF: Are some of Kaiser’s regional ambitions starting to pay off? We h…

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The coming site-of-care shock for infusions

  • Biopharma , 
  • Payers , 
  • Providers
There’s a major disruption looming in how the site-of-care for infusio…

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The road ahead for genomic testing

  • Biopharma , 
  • Payers , 
  • Medtech , 
New molecular diagnostics, especially tests based on next-generation s…

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Optum opening new competitive terrain in Revenue Cycle Management

  • Payers , 
  • Providers
What is revenue cycle management? Revenue cycle management (RCM) is th…

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Profit engine swap-outs: How UPMC sustained itself after the Highmark decoupling

  • Payers , 
  • Providers
UPMC’s decoupling from Highmark exposed a critical vulnerability: econ…

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How much are Humana’s value-based care models really taking out of utilization?

  • Payers , 
  • Providers
All that effort for only 0.4% savings Since 2014, HUM has reported on …

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AI in healthcare III: COVID-19 applications and implications

  • Biopharma , 
  • Payers , 
  • Providers , 
  • Medtech , 
  • Digital , 
COVID-19 has accelerated the adoption of AI in healthcare. AI based to…

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Buying kit for a leadership position in the @Home revolution? Implications of Optum’s acquisition of naviHealth

  • Payers , 
  • Providers
Summary NaviHealth is a leader in post-acute care management; since i…

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Covid’s backhand blow: payer mix degradation and the threat of renewed payer/provider rate brawls

  • Payers , 
  • Providers
Among Covid’s many repercussions, the recession shock will drive a sus…

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Medicare Advantage’s durable – but underexplained – post-acute care advantage

  • Payers , 
  • Providers
Health Affairs has put out another study – this one by Skopec and team…

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Strategy in the Time of Covid

  • Biopharma , 
  • Payers , 
  • Providers , 
  • Medtech , 
  • Digital , 
Preamble A recent post from Recon Strategy outlined the longer-term st…

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The day after: Implications for hospitals, payers, biotech and more…

  • Biopharma , 
  • Payers , 
  • Providers , 
  • Medtech , 
  • Digital
Even as our priority today is dealing with the Covid crisis, healthcar…

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Bolting a full-risk engine onto an urgent care chassis in New York

  • Payers , 
  • Providers
Last month, Warburg Pincus closed on previously announced plans to acq…

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Facing new vertically integrated competitors, WellSpan and Capital Blue Cross prepare for a long siege

  • Payers , 
  • Providers
Summary The Capital Region of Pennsylvania is shifting in “real time”…

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OptumCare’s legacy entanglements could slow its site-of-service shift

  • Payers , 
  • Providers
By bringing together accountable-minded physicians, urgent care and am…

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There’s always a bigger fish: healthcare services giants are looking anxiously over their shoulders

  • Payers , 
  • Providers , 
  • Digital , 
With the closing of the CVS/AET and CI/ESRX combinations, healthcare s…

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Consider this speculative scenario on WMT-HUM: nibbling at the bottom and taking a slice off the top of the healthcare delivery pyramid

  • Payers , 
  • Providers , 
WMT is in talks with HUM about a relationship enhancement, possibly an…

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Google’s health insurance apprenticeship: some unicorns (maybe) but no masterpieces

  • Payers , 
  • Digital , 
Last month, word got out that Verily is in talks with health plans to …

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Consider this speculative Amazon scenario in your strategic planning

  • Payers , 
  • Providers , 
Amazon has many puzzled about its plans for healthcare. Arguably, Amaz…

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The UPMC/Highmark brawl spills into Philadelphia’s backyard – what happens next?

  • Payers , 
  • Providers
(For background on Pennsylvania market, please take a look at previous…

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With the DaVita Medical Group acquisition, OptumHealth deepens its presence in existing markets rather than adding new ones

  • Payers , 
  • Providers
OptumHealth and its proposed acquisition target DaVita Medical Group (…

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United’s ambulatory delivery system OptumCare can reach 70% of the US population

  • Payers , 
  • Providers
Who will be the first to take integrated health care delivery national…

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UPMC’s race to the sea and the tentative steps towards Highmark-Geisinger alliance

  • Payers , 
  • Providers
On May 10, Highmark and Geisinger announced plans for a clinical joint…

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A population health approach to value-based drug pricing

  • Biopharma , 
  • Payers
Working Paper   Summary Drug companies are naturally incentivized…

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Biopharma risk-sharing: what needs to happen

  • Biopharma , 
  • Payers , 
  • Providers
A couple of years ago, we addressed the question of whether drug compa…

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Context is King – When to use an Agile corporate strategy?

  • Biopharma , 
  • Payers , 
  • Providers , 
  • Digital , 
“Agile corporate strategy” (as defined in a previous post) is already …

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Mercy Health exits the insurance business and curtails ambitions for its state-wide provider alliance

  • Payers , 
  • Providers
Earlier this month, Mercy Health announced deals to dismantle HealthSp…

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Centene bringing a new managed care strategy to The Big House?

  • Payers , 
  • Providers
Correctional health and correctional pharmacy 2.2M people are incarcer…

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Ohio’s Mercy-Summa alliance grows contracting teeth

  • Payers , 
  • Providers
Mercy Health – the largest system in Ohio – has recently formed a Clin…

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Working paper: the coming age of algorithmic medicine

  • Payers , 
  • Providers , 
  • Digital , 
Summary In this working paper, we develop the following thesis. In the…

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Can convenience care be a platform for an insurance product?

  • Payers , 
  • Providers , 
Summary A Portland-based urgent care operator is launching a health p…

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A sizeable step forward but miles still to go: CMS’ Next Generation ACO model

  • Payers , 
  • Providers
CMS has issued a “Request for Applications” describing its Next Genera…

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Shifting lines in the mobile health competitive battlefield: Aetna makes a strategic retreat while United digs in?

  • Payers , 
  • Digital
The battle to own healthcare’s consumer relationship is being nowhere …

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The “weaponization” of ACO narrow networks: Strategic destabilizers which compel their own replication?

  • Payers , 
  • Providers
In theory, narrow networks built around a single provider or a network…

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Can drug companies make drugs, AND money?

  • Biopharma , 
  • Payers
In this morning’s New York Times (June 3,2014), Andrew Ross Sorkin ask…

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Aetna not conceding the private exchange space to the benefits consultants

  • Payers
Summary Aetna is stitching its inventory of ACO deals into a national…

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Boiling the Ocean…or not

  • Payers , 
  • Providers , 
  • Digital , 
We've all heard the term, "Boiling the Ocean" to refer to an approach …

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MA hospital relative prices by payer

  • Payers , 
  • Providers
Here's a quick look at relative prices in MA using CHIA data for you t…

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Cigna and Samsung: assembling a “global account”-based business model for mobile

  • Payers , 
  • Digital
Samsung and Cigna have agreed to a multi-year development alliance for…

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Marrying into the right family: the bets underlying United’s revenue cycle management joint venture with Dignity Health

  • Payers , 
  • Providers
Market for outsourced revenue cycle management could be big The revenu…

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Strategic “crowd-out” via narrow networks: an emerging case study in Wisconsin

  • Payers , 
  • Providers
Last week, I argued that, if payers want to secure competitive advanta…

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ACO proliferation and provider “all-payer” care models inexorably lead to tighter network strategies

  • Payers , 
  • Providers
A new study in JAMA (by McWilliams et al.) looks at the Medicare expen…

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Making flanks something for the enemy to worry about: the Cleveland Clinic-Promedica deal and the emerging battle for northern Ohio

  • Payers , 
  • Providers
Summary Earlier this year, Catholic Health Partners, the largest prov…

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Could the Employer Mandate lead to reduced coverage?

  • Payers
When it comes to employee benefits, employers need to be generous eith…

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Ambidextrous strategy: PART 2 – Scenario Implications

  • Payers , 
  • Providers
In our last post we introduced two potential scenarios. "Provider bas…

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Ambidextrous strategy: PART 1 – Payer and provider strategy for two very different worlds

  • Payers , 
  • Providers
It seems like every day there’s some news outlining strategic actions …

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Could a delay in the employer mandate be a boost to government run exchanges?

  • Payers
In 2011 we commented that while the health reform law, the ACA, had se…

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When do you know ACOs are here to stay?

  • Payers , 
  • Providers
Answer:  When they form an industry association! Back in February, a …

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Risk-taking providers in private exchanges: Medica’s “My Plan” private exchange

  • Payers , 
  • Providers
At a TEDMED conference a couple years ago, I had to write some sample …

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Getting the troubled Highmark-West Penn relationship back on track: an outside-in speculation

  • Payers , 
  • Providers
Summary Highmark and the West Penn Allegheny Health System (WPAHS) ar…

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Romance of convenience: perspectives on the IASIS-Aurora joint venture

  • Payers , 
  • Providers
Summary Two major hospital systems have agreed to a joint venture to …

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Clear Health Alliance: Debut of the for-profit HIV/AIDS special needs plan

  • Payers
Summary HIV Special Needs Plans (SNPs) offer extra layers of servic…

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Rescuing the condition-focused ACO from CMS

  • Payers , 
  • Providers
Summary The case for an oncology ACO can be compelling but CMS rule…

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Transitioning from patchwork to quilt: NY and PA’s path to integrating HIEs at the state level

  • Payers , 
  • Providers
Last month, NY and PA announced plans for how they will integrate data…

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Heartland Health: Marching towards Kansas City with Mayo on its shoulder

  • Payers , 
  • Providers
Earlier this month, Heartland Health signed a deal with the Mayo Clini…

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The Blues system and PHIXs: not standardizing on a single utility

  • Payers
BCBSMN has licensed the platform for its private health insurance exch…

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Towers Watson’s bold move in private insurance exchanges: leapfrog Aon and leave Mercer’s alliance compromised

  • Payers
With its acquisition of Extend Health, Towers Watson has ensured that …

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Big box retail as health insurance channel: thoughts on the Aetna-Costco deal

  • Payers
Summary Aetna has struck a deal to sell individual health insurance w…

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Payment reform: some observations on skepticism

  • Payers
There have been some blog posts (here and here) about a discussion on …

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The ASO escape hatch for small group: California says “not so fast”

  • Payers
Next week, the California insurance commissioner will propose legislat…

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Lumeris, NaviNet and the emerging battle for cloud-based ACO enablement

  • Payers , 
  • Providers
Summary Administrative clearinghouse NaviNet has been acquired by 3 B…

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Compete by creating more competitors: the Heartland Health deal and Aetna’s strategic jiu jitsu

  • Payers , 
  • Providers
Yesterday, Aetna announced a deal with Heartland Health (an integrated…

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Aetna and Best Buy: a new twist on retail in healthcare

  • Payers , 
  • Providers
Aetna has struck a deal with Best Buy to sell four online coaching pro…

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“Savings illusion” can become savings reality in the long haul: baby boomers to the rescue

  • Payers , 
  • Providers
A recent article in the NEJM argues that cost savings from quality imp…

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Bubble in acquisition pricing of Medicare Advantage lives?

  • Payers
Several recent acquisitions suggest a rapidly growing valuation on Med…

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XL Health in play: what do the three suitors see?

  • Payers
UPDATE: United buys XL Health! Here's what we surmised in the origin…

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Emerging Unintended Consequences of Health Care Reform

  • Payers , 
  • Providers
In complex system, even small changes can have big, unexpected consequ…

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The CIGNA-Healthspring deal: local share key to top-line synergies but still missing from the equation

  • Payers , 
  • Providers
Summary Provider discounts are a key priority for national accounts –…

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Six strategic choices made by CMS in the final ACO rules

  • Payers , 
  • Providers
1. The final ACO rules largely maintain the demanding economic paramet…

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Narrow networks: adoption growing among smaller groups

  • Payers , 
  • Providers
Kaiser’s latest employer benefits survey offers some interesting data …

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Private health insurance exchanges and defined contribution: thoughts on Wellpoint’s acquisition of Bloom Health

  • Payers
Why would a health plan want to buy an exchange? Isn’t the only syner…

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The Steward-Tufts deal and the looming threat of provider-led narrow network insurance

  • Payers , 
  • Providers
The Stewards-Tufts deal announced today will create a narrow network i…

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A gradual roll-out of ACOs will minimize disruption and resistance

  • Payers , 
  • Providers
Part of the theory of ACO value creation is trading off more primary c…

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Upping in ante in Pittsburgh: the health information exchange arms race

  • Payers , 
  • Providers
A few weeks ago, UPMC announced an agreement among nine area systems t…

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Provider incentives in the commercial ACO: retaining a small share of savings in return for future volme growth

  • Payers , 
  • Providers
Earlier this month, Blue Shield of California announced 2010 results f…

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Partners’ acquisition of Neighborhood Health Plan: reinforcing the role of community health centers in the care continuum

  • Payers , 
  • Providers
Much of the public speculation (for example here and here) regarding t…

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The curious absence of payers in public HIEs

  • Payers
Last week, the National eHealth Collaborative published a study of sus…

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Medicaid going mainstream: thoughts on the IBC / BCBSM / AmeriHealth deal

  • Payers
Historically Blues have shied away from Medicaid. Two thirds of plans …

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ESRX-MHS Part 2: mail facility speculations (…or: Indulging my Inner SWAGer)

  • Payers
Summary ESRX was running at close to maximum capacity at its mail fa…

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ESRX-MHS Part 1: Last stand of the PBM pure play: observations on the Medco-Express combination

  • Payers
UNH’s decision to take the commercial PBM business in-house did not fo…

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Highmark and West Penn: it’s about mitigating consolidation, not transforming the system

  • Payers , 
  • Providers
Highmark will invest up to $475M in the West Penn Allegheny Health Sys…

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Did Wellpoint overpay for Caremore? No….not yet anyway

  • Payers , 
  • Providers
Summary Wellpoint probably paid full value for Caremore (if that comp…

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Blue Shield of California’s unilateral profit cap: competitive gambit or PR move?

  • Payers
Summary: Blue Shield of California (BSC) has committed to keeping pro…

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Employer opt-out as a result of reform: survey vs. model

  • Payers
Yesterday, McKinsey released a report suggesting that 30% of employers…

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Rapid shift to “bare bones” coverage among Massachusetts small employers: preview of Federal reform impact?

  • Payers
Summary Massachusetts small group went from an average actuarial valu…

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Rise of self-insurance in smaller groups: opportunity and threat

  • Payers
Summary  Self-insurance is growing among smaller groups (includi…

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Major health plan Q1 earnings: Profit surprise in commercial risk; multiple reasons why business prospects look good

  • Payers
Public health insurers startled the market with earnings ~25% above co…

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ACO profitability: Reasons for optimism

  • Payers
Summary A new article in the NEJM suggests ACO economics will be unat…

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Primary care capacity and the looming Medicaid surge: Medicaid-focused providers must be part of the answer

  • Payers , 
  • Providers
Summary A new study from Center for Studying Health System Change su…

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Revolution in Roanoke? Perspectives on the Aetna-Carilion deal

  • Payers , 
  • Providers
Summary  The line between health plan and provider continues to …

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How can a health plan weather the MLR hit to profitability? Some clues from Coventry

  • Payers
Summary Health plan profits will be down dramatically in 2011 due to …

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Surprising implication of drivers of Medicare FFS variation – MedPAC

  • Payers
New MedPAC report on Medicare fee for service utilization finds l…

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Health care reform not so easy to derail

  • Payers
Prediction 1: Despite all the beating of drums we do not think there w…

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If you’re on Medicare – don’t fall sick

  • Payers
A friend of mine pointed out some shocking data from a report released…

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