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Under CJR-X, quality decides more than cost: Two former CMS officials on what the earlier bundles reveal
Key Highlights Introduction › Interview › What this means for your hospital › With the CJR-X final rule now released in July 2026, the first mandatory, nationwide episode-based payment model for lower extremity joint replacement is set to begin on January 1, 2028. For most acute care hospitals, participation is now settled and required, and … Under CJR-X, quality decides more than cost: Two former CMS officials on what the earlier bundles reveal
Mitigating the impact of high-cost claimants: A payer analytics approach to total cost of care
It has long been understood that a relatively small portion of any covered population accounts for a disproportionately large share of healthcare spending. A 2025 study by the Employee Benefit Research Institute (EBRI), which examined 13.1 million individuals with employer-sponsored health coverage in 2022, found that the highest-cost 20% of members were responsible for 84% … Mitigating the impact of high-cost claimants: A payer analytics approach to total cost of care
Why VBC still fails for mature organizations: What actually separates high performers
Value-based care (VBC) has moved well beyond experimentation. For many healthcare organizations, value-based contracts now represent a significant share of revenue, risk exposure, and strategic focus. The industry has largely resolved the question of whether to participate in these models. What remains unresolved is how to manage them most effectively. Increasingly, a common source of … Why VBC still fails for mature organizations: What actually separates high performers
CJR-X starts January 2028. The hospitals that win are starting now
CMS has finalized the first nationwide expansion of an episode-based payment model, and by its own account the largest such model in Medicare’s history: a mandatory program covering lower extremity joint replacements (LEJR). It is called CJR-X, short for Comprehensive Care for Joint Replacement Expanded, and it begins January 1, 2028, as an ongoing program … CJR-X starts January 2028. The hospitals that win are starting now
Turn total cost of care strategy into measurable action
Healthcare payers are under growing pressure to reduce costs while managing rising utilization, unit cost, pharmacy spend, and medical expense trends. But analytics alone are not enough. To create measurable impact, health plans need trusted data, actuarial alignment, enterprise governance, and a repeatable process for turning insights into action. In this case study, see how … Turn total cost of care strategy into measurable action
The decade of full risk starts now: Four workflows separate ACOs ready for it
The conditions for value-based care (VBC) have just shifted, as stronger financial results, improved data usability, and new long-term CMS incentives reshape what it takes for Accountable Care Organizations (ACOs) to compete and succeed. ACOs have had access to Centers for Medicare & Medicaid Services (CMS) claims data for years. What has made the difference … The decade of full risk starts now: Four workflows separate ACOs ready for it
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MA Plan identifies hidden cost drivers and recovers millions through deeper inpatient cost transparency
When a Midwest provider of MA plans was facing mounting costs that its legacy analytics capabilities could not explain, the organization sought help with analyzing utilization costs by facility, market and product, and surfacing trends and insights that could identify cost-saving opportunities. Without the ability to drill down into cost drivers, the unjustifiably high acuity … MA Plan identifies hidden cost drivers and recovers millions through deeper inpatient cost transparency
Research hospital executes a challenging shift to more cost-effective clinical care
When one of the country’s flagship research hospitals sought to shift from high-cost academic work to more cost-effective and sustainable clinical care, the organization began a restructuring designed to improve clinical and financial outcomes in its population of approximately 645,000 at-risk patients, with a focus on the Medicare Shared Savings Program (MSSP) and Medicaid. To … Research hospital executes a challenging shift to more cost-effective clinical care
From insight to action: What the value-based care survey reveals
Value-based care organizations face a difficult question: whether their teams can act on analytic insight consistently, within the data and workflows they operate each day. The Milliman MedInsight value-based care survey posed that question to a broad range of provider organizations. The responses show that most regard analytics as essential, while their progress toward operational … From insight to action: What the value-based care survey reveals
New report shows how healthcare payers are using analytics and AI to drive impact
Healthcare payers are making big investments in analytics, AI, and digital transformation with the goal of translating data into bottom line efficiencies and improved member experiences. For many payers, however, system integration, staffing, and improved data quality are needed to fully translate analytics investments into the operational gains they are seeking. Those are among the … New report shows how healthcare payers are using analytics and AI to drive impact
Beyond the model: How leading organizations will win under CMS LEAD RFA
A recap of our May 7 webinar If you missed our live session, “How leading organizations will win under CMS LEAD RFA,” don’t worry. My colleague Jonah Broulette, Principal and Consulting Actuary at Milliman, and I walked our audience through what’s actually new in CMS’s LEAD model, how it stacks up against MSSP, and the … Beyond the model: How leading organizations will win under CMS LEAD RFA
Data-driven payer strategies: Survey insights and solutions
Health plans are investing heavily in analytics and AI, but many still struggle to turn insight into meaningful action. Join MedInsight for a data-driven discussion of findings from our Payer Market Survey, and what they reveal about the widening gap between analytics ambition and operational impact. As margin pressures mount, organizations are prioritizing cost and utilization analytics like never before, yet effectiveness in managing … Data-driven payer strategies: Survey insights and solutions
