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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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From noise to signal: How ACOs use analytics to gain confidence in a changing CMMI landscape
Increasing uncertainty – driven by changing CMS/CMMI models, MA HCC updates, and Medicaid funding pressures – demands data-driven clarity. Milliman will show how ACOs leverage analytics to build confidence, with practical discussions on fraud monitoring, risk score analytics, and readiness for models like LEAD, TEAM, ASM, and ACCESS.
Learn how payers are using analytics and AI to drive impact: Insights and trends
Health plans of all sizes recognize that strong analytics capabilities are essential to future success. In particular, analytics support reliable evaluation of cost and utilization patterns, quality and outcome measures, and risk adjustment. However, major challenges remain, integrating new technology with legacy systems and addressing limited and analytic resources. The Milliman MedInsight Executive Report explores … Learn how payers are using analytics and AI to drive impact: Insights and trends
New report offers a glimpse into how VBC organizations view the role of analytics in their clinical and business goals
With benchmarks tightening and growing pressure to maximize cost and utilization efficiency under the value-based care model, healthcare provider organizations of all sizes are turning to analytics for answers. As part of our 2025 Provider Market Survey, Milliman MedInsight sought input from provider organizations on their analytics priorities and challenges as well as their vision … New report offers a glimpse into how VBC organizations view the role of analytics in their clinical and business goals
CMS’s new ACO LEAD model
The Centers for Medicare & Medicaid Services’ (CMS) Long-term Enhanced Accountable Care Organization (ACO) Design (LEAD) model presents a significant opportunity to improve care coordination, financial alignment, and outcomes for individuals dually eligible for Medicare and Medicaid. This paper summarizes key themes and strategic considerations from Milliman’s analysis of the LEAD model, highlighting potential implications … CMS’s new ACO LEAD model
From insight to action: Operationalizing physician performance in value-based care
In Part 1 of this series, Physician performance enablement: Engaging providers with actionable insights for ACO success, we explored the foundational elements required to build physician engagement in value-based care (VBC). Engagement creates shared understanding and alignment, but it is only the starting point. Organizations that consistently succeed in VBC move beyond engagement to physician … From insight to action: Operationalizing physician performance in value-based care
Becker’s Payer Issues Roundtable Recap: Key insights for health plan leaders
At this year’s Becker’s Payer Issues Roundtable, one message came through consistently: the challenge for payer organizations isn’t new ideas. They need execution that measurably bends trend while keeping decisions defensible in a more scrutinized environment. Across markets, leaders described a world of tighter margins, higher acuity, member disruption, and growing expectations that plans will … Becker’s Payer Issues Roundtable Recap: Key insights for health plan leaders
