Podcasts about Managed care

It's In the News.. a look at the top headlines and stories in the diabetes community. This week's top stories: big FDA recall around Freestyle Libre (see more below to find out if you're affected), Dexcom launches their 15.5 day sensor, Omnipod announces enhancements, Tandem tests a fully closed loop (with high fat, high carb meals) and lots more! Find out how to submit your Community Commercial Find out more about Moms' Night Out  Please visit our Sponsors & Partners - they help make the show possible! Learn more about Gvoke Glucagon Gvoke HypoPen® (glucagon injection): Glucagon Injection For Very Low Blood Sugar (gvokeglucagon.com) Omnipod - Simplify Life Learn about Dexcom   Check out VIVI Cap to protect your insulin from extreme temperatures The best way to keep up with Stacey and the show is by signing up for our weekly newsletter: Sign up for our newsletter here Here's where to find us: Facebook (Group) Facebook (Page) Instagram Twitter Check out Stacey's books! Learn more about everything at our home page www.diabetes-connections.com  Reach out with questions or comments: info@diabetes-connections.com Episode transcription with links: Hello and welcome to Diabetes Connections In the News! I'm Stacey Simms and every other Friday I bring you a short episode with the top diabetes stories and headlines happening now. Our top story this week: XX Certain glucose monitors from Abbott Diabetes Care are providing users with incorrect glucose readings, an error that has been linked with the deaths of at least seven people and more than 700 serious injuries worldwide, according to an alert from the US Food and Drug Administration.   Incorrect glucose readings can lead to improper treatment. Abbott warned that about 3 million FreeStyle Libre 3 and FreeStyle Libre 3 Plus sensors are affected, but no other Libre products. Patients can visit FreeStyleCheck.com to see if their sensors are affected and to get a replacement for free.   The FDA has also published specific information about the affected products in its alert. The agency considers this to be a "potentially high-risk issue" and will continue to update its website as information becomes available.   "Patients should verify if their sensors are impacted and immediately discontinue use and dispose of the affected sensor(s)," the FDA said.   https://www.cnn.com/2025/12/02/health/abbott-diabetes-glucose-monitors https://www.freestylecheck.com/us-en/home.html XX Omnipod 5 is getting some enhancements.. and Omnipod 6 is announced. The FDA cleared updates including  a lower, 100 mg/dL target glucose option and what they call a more seamless automated experience. "This is the most significant algorithm advancement to our Omnipod 5 System since its launch in 2022," said Eric Benjamin, Insulet EVP and COO. Insulet said the new 100 mg/dL target glucose expands Omnipod 5's customization range. It now features six settings between 100 mg/dL and 150 mg/dL in 10 mg/dL increments. The company said this flexibility allows healthcare providers to tailor insulin delivery more precisely. It supports individuals seeking tighter glucose management or aiming to meet specific glucose goals. Omnipod 5's latest upgrades also help users stay in "Automated Mode" with fewer interruptions, even during prolonged high glucose events. Insulet plans to launch the updates to the algorithm in the first half of 2026. The company announced plans for an Omnipod 6 – without a lot of detail - at the company's Investor Day event in November. They also talked about a new, fully closed-loop pump for the type 2 diabetes population. https://www.drugdeliverybusiness.com/insulet-fda-clearance-omnipod-5-algorithm-enhancements/ XX Dexcom, the global leader in glucose biosensing, announced today that the Dexcom G7 15 Day Continuous Glucose Monitoring (CGM) System will launch in the United States on Dec. 1, making it the longest-lasting CGM system with 15.5 days of wear.   Dexcom G7 15 Day will first be available through durable medical equipment (DME) providers on Dec. 1 with full retail launch in the coming weeks. Dexcom G7 15 Day will also be covered for Medicare beneficiaries.   Dexcom G7 15 Day's industry-leading wear-time will provide fewer sensor changes, less disruption and more time for people with diabetes to benefit from life-changing CGM technology.   New with Dexcom G7 15 Day:  Longest lasting CGM system with 15.5 days of wear. Best-in-class accuracy1 with an overall MARD of 8.0%. Easier glucose management with fewer monthly sensor changes and reduced monthly waste. This follows yesterday's announcement – the FDA has cleared Dexcom Smart Basal, the first and only CGM-integrated basal insulin dosing optimizer designed for adults 18 and older with Type 2 diabetes using long-acting insulin. Dexcom Smart Basal will use Dexcom G7 15 Day sensor data and logged doses to calculate personalized daily recommendations to guide users towards a more effective long-acting insulin dose, as directed by their healthcare provider. At launch, Dexcom G7 15 Day will connect with the iLet Bionic Pancreas and Omnipod® 5§§. We are working closely with Tandem and look forward to extending the launch to their customers shortly as they finalize integration. For specific information on pump compatibility and availability with the Dexcom G7 15 Day system, visit Dexcom.com/connectedpumps https://investors.dexcom.com/news/news-details/2025/Dexcom-G7-15-Day-Continuous-Glucose-Monitoring-System-to-Launch-on-Dec--1-in-the-United-States/default.aspx   XX A small study of ten adults with type 1 diabetes tested Tandem's new fully closed-loop "Freedom" insulin system — and the participants put it through a real-world stress test. For 72 hours in a hotel setting, they ate heavy carb-and-fat meals, skipped all meal announcements, and didn't give any mealtime insulin boluses. The system handled almost everything automatically. Researchers said the device stayed in closed-loop mode 97% of the time and there were no incidents of diabetic ketoacidosis or severe hypoglycemia reported. While using the Freedom system, participants spent a median 61% of the day in the glucose target range — slightly higher than the 56% achieved with their usual pump at home. But the biggest improvement came overnight: time in range jumped to 96% with the closed-loop system compared to just under 70% during their home-pump week. With almost zero time spent below 70 mg/dL, researchers concluded that the fully automated Tandem system was both safe and effective even with unannounced, high-impact meals — hinting at a future of diabetes management that demands less effort from users.   XX Novo Nordisk reported promising mid-stage results for its experimental drug amycretin (AM-ee-creht-in) in diabetes patients on Tuesday. Amycretin, targets both GLP-1 and amylin hormones. In this study, it helped patients with type 2 diabetes lose up to 14.5% of their body weight over 36 weeks with weekly injections, far outperforming a placebo. The oral version delivered weight loss of up to 10.1%. Rival Eli Lilly  is surging ahead with its own amylin-based drug, eloralintide, which is advancing to late-stage testing after helping patients shed as much as 20% of their weight in a mid-stage trial. https://www.cnbc.com/2025/11/25/novos-next-gen-obesity-drug-shows-positive-results-heads-to-late-stage-testing.html XX The U.S. Medicare health plan said on Tuesday that newly negotiated prices for 15 of its costliest drugs will save 36% on those medications compared with recent annual spending, or about $8.5 billion in net covered prescription costs. The prices go into effect in 2027, including a monthly price of $274 for Novo Nordisk's popular GLP-1 drug semaglutide, sold as Wegovy for weight loss and Ozempic for diabetes. medicare's recent net price for Ozempic, opens new tab was $428 a month, according to an analysis published in the Journal of Managed Care and Specialty Pharmacy. Medicare put the drug's list price, before confidential rebates and discounts, at $959 a month. Based on such nondiscounted list prices, Medicare said savings on the 15 drugs ranged from 38% to 85%. The annual price negotiations were established under President Joe Biden's signature Inflation Reduction Act (IRA) of 2022. Previously, Medicare was barred by law from negotiating with drugmakers. https://www.reuters.com/business/healthcare-pharmaceuticals/us-negotiated-medicare-prices-15-more-drugs-test-cost-savings-promise-2025-11-25/   XX LifeScan announced its Chapter 11 bankruptcy reorganization plan received U.S. Bankruptcy Court approval. LifeScan said it's positioned to emerge from its financial restructuring process by the end of the year. The CEO says, "This balance sheet restructuring provides a stronger foundation for LifeScan to support our base business, advance new growth strategies, and commence our journey to become one of the most comprehensive players in the glucose management space." https://www.drugdeliverybusiness.com/glucose-monitor-lifescan-emerge-from-bankruptcy/ XX An artificial intelligence (AI)-led Diabetes Prevention Program (DPP) was as effective as a traditional human-led program in achieving recommended goals for weight loss, A1c reduction, and physical activity, according to a randomized trial of adults with prediabetes and overweight or obesity. One example of a push notification: "Looks like you're at the grocery store, Rita! Want a quick list of high-fiber snacks or smart swaps to stay on track this week?" The app also provided location- and goal-based education, with gamification elements to promote engagement. Approximately one third of participants in both the AI and human-led groups achieved the primary outcome (31.7% and 31.9%, respectively). Results were consistent across sensitivity analyses and individual components of the composite endpoint. "As more AI-based programs emerge, head-to-head comparisons among different AI-DPPs will be informative. An AI-led approach will not suit everyone; some individuals benefit more from human interaction and accountability," said Mathioudakis, adding that future research should focus on best matching patients to the modalities they prefer. https://www.medscape.com/viewarticle/ai-directed-diabetes-prevention-program-effective-human-2025a1000xam XX A new study suggets metformin could help people with type 1, reducing the need for insulin.  The researchers were surprised to find that metformin did not improve insulin resistance or change blood sugar levels. This suggests that, unlike in type 2 diabetes, metformin doesn't combat insulin resistance in type 1 diabetes.   However, metformin did reduce the amount of insulin people needed to keep their blood sugar levels stable.   https://www.the-express.com/news/health/192157/diabetes-medicine-insulin-type-1 XX Beyond Type 1 launches #TheBeyondType campaign in India to combat type 1 diabetes stigma. Nick Jonas is one of the founders of Beyond Type 1, his wife, Priyanka Chopra Jonas is his partner in this new non profit. The initiative highlights inspiring individuals living with T1D and partners with local organisations to improve awareness, medical support, and community networks for affected families across the nation. India has more young people living with T1D than any other nation, yet understanding of the condition remains limited. Beyond Type 1 is partnering with grassroots organisations across high-need regions. These include HRIDAY in Delhi–NCR, Nityaasha Foundation in Pune, Gram Jyoti in Jharkhand, and SAMATVAM Trust in Bangalore—each group focusing on improving awareness, providing medical support and building stronger community networks for young people with T1D.

In this episode, Tom Buckley shares the biggest revenue cycle challenges facing health systems today, from payer denials to rising patient financial responsibility, and how Virtua Health is using AI, automation, and strong communication practices to stay ahead. He also reflects on evolving leadership expectations and what it takes to keep teams resilient and aligned in a rapidly changing environment.

Today we are bringing you a conversation on the evolving landscape for idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) treatment. Ryan Haumschild, PharmD, MS, MBA, vice president of ambulatory pharmacy at Emory Healthcare and Winship Cancer Institute, spoke with Marilyn Glassberg, MD, the John W. Clarke Professor and Chair of medicine at Loyola University Chicago Stritch School of Medicine; Ayodeji Adegunsoye, MD, MSc, PhD, FACP, FCCP, assistant professor at the University of Chicago; and Janet Pope, MD, MPH, professor of medicine and division member of rheumatology at the University of Western Ontario in Canada. IPF and PPF are increasingly prevalent conditions that pose a growing burden on both patients and health care systems. Despite the availability of FDA-approved antifibrotic therapies, the median survival for patients with IPF and PPF remains less than 5 years after diagnosis—underscoring the critical unmet needs that persist in this field. The panelists discussed the impact these conditions have on patients' lives, evaluated emerging agents, and addressed economic considerations that affect treatment decisions and health care resource allocation.

Host Andy Demetriou talks with Tricia Asaro of Greenberg Traurig about the history and evolution of managed care, the key players in the industry, current affordability and access challenges and her perspectives on the future of managed care.

In this episode of the NASP Podcast, Sheila Arquette, President & CEO of NASP, speaks with Matthew G. Bowles, PharmD, MBA, CSP, Pharmacy Clinical Team Lead with Vanderbilt Specialty Pharmacy, Vanderbilt Health, and lead author on the study “Getting to specialty treatment in dermatologic inflammatory conditions: Treatment requirements and patient journey,” published February 2025 in the Journal of Managed Care & Specialty Pharmacy. They discuss the reasons for conducting and results of the study, as well as the impacts the study may have on specialty and managed care pharmacy.

On this episode of Managed Care Cast, Rachel A. Prusynski, DPT, PhD, an assistant professor at the University of Washington's School of Medicine, speaks with The American Journal of Managed Care® about her research published in the November 2025 issue. Her study, "Medicare Advantage Reimbursement Structures Impact Home Health Delivery and Outcomes," explores how home health care delivery and patient outcomes differ between 3 plan types: traditional Medicare, episodic Medicare Advantage, and per-visit Medicare Advantage. Throughout the conversation, Prusynski discusses what motivated the research, the study's key findings, and the broader implications for improving the quality and accessibility of future home health care.

Nick Wood, speaking at the Kansas InterHab conference, discusses the role of InterHab as a statewide trade association supporting providers for people with intellectual and developmental disabilities (IDD). He emphasizes the benefits of collaboration, communication, and training among member organizations, as well as advocacy for policy improvements. Key challenges include workforce shortages, recruitment and retention of direct support professionals, and the need for person-centered approaches. Wood also explores the complexities of managed care in Kansas, highlighting its unique full-risk Medicaid model and the importance of integrating medical, behavioral, and long-term supports. He calls for better training, common language, and innovative solutions to address waiting lists and improve health equity for individuals with IDD.

CJ Dietzman and Tara Albin, Alliant Cyber, are joined by Kenny White, Alliant Healthcare, to examine the evolving role of artificial intelligence in the managed care industry. Their discussion explores how AI is streamlining administrative processes and compliance functions, while simultaneously introducing new exposures around privacy, vendor accountability and cyber risk. Together they highlight how proactive strategies such as implementing governance frameworks, employee training and AI literacy in an organization can strengthen resilience and manage risk in an increasingly automated environment.

         Medicare Advantage Minute:                                                                                Medicare users could soon lose perks they love, like choosing their own doctors!           Your Medicare Benefits 2025:                                                                            Shingles Shots We review recent rate increase filings in various states by various insurance companies. Is Medical inflation still with us or is it starting to subside? Contact me at: DBJ@MLMMailbag.com (Most severe critic: A+)                   Visit us on: BabyBoomer.ORG Inspired by: "MEDICARE FOR THE LAZY MAN 2025; SIMPLEST & EASIEST GUIDE EVER!" "MEDICARE DRUG PLANS: A SIMPLE D-I-Y GUIDE" "MEDICARE FOR THE LAZY MAN: BARE BONES!" For sale on Amazon.com. After enjoying the books, please consider returning to leave a short customer review to  help future readers. Official website: https://www.MedicareForTheLazyMan.com.

Today we are bringing you a conversation on how topical therapies can effectively manage atopic dermatitis. Brian Keegan, MD, PhD, FAAD, a dermatologist with Princeton Dermatology, spoke with Alexa Hetzel, MS, PA-C, physician assistant with Schweiger Dermatology Group; Vikash D. Oza, MD, director of pediatric dermatology at NYU Langone; and Amy Spizuoco, DO, FAOCD, dermatologist and dermatopathologist at True Dermatology. In addition to discussing the clinical benefits and impact on patient outcomes of using topical therapies for atopic dermatitis, the panelists explored how health economics research informs treatment decisions by demonstrating the cost-effectiveness and accessibility of topical therapies. The panel also analyzed the potential health care cost savings and resource optimization achieved through strategic use of topical treatments and atopic dermatitis management.

Research is more than just finding interesting stats. It's about finding better ways to deliver savings, simplicity, and support. In this episode, you'll hear from managed care pharmacy researchers who are doing just that, delivering data driven insights to drive affordability and access in health care.  Pat Gleason, PharmD, BCPS, FCCP, FAMCP, assistant vice president of health outcomes; Nick Friedlander, PharmD, clinical program pharmacist; and Simone Ndujiuba, PharmD, BCOP, clinical oncology pharmacist senior principal; and host Alex Cook, senior public relations manager, discuss how Prime's research helps address affordability and accessibility issues and guides health care providers and peers toward clarity on treatment for complex health conditions. Research topics covered:Three-Year Real-World Adherence and Persistence to Glucagon-Like Peptide-1 Receptor Agonists Among Commercially Insured Adults with Obesity without Diabetes Trends in Real-World Persistence to Weight Loss Glucagon-Like Peptide-1 Receptor Agonists from 2021 to 2024 Among Commercially Insured Adults without Diabetes — This study earned a platinum award from AMCP.  Impact of a Medical Claims Automated Glucagon Like Peptide-1 Drugs Prior Authorization Program— This study earned a gold award from AMCP.Validation of Long-term Savings from a Pharmacist-to-Prescriber Telephonic Intervention — This study earned a gold award from AMCP. Total Cost of Care and Adverse Effects Assessment of Bispecific T-cell Engagers and Chimeric Antigen Receptor T-cell Therapies for Relapsed Refractory Follicular Lymphoma  -------------------------Content in this podcast is for informational or educational purposes only.The content also does not substitute professional medical advice or consultations with health care professionals. Always seek advice from a physician or other health care providers with any questions you have regarding a medical treatment or condition before undertaking a new health care regimen.

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Melanie T. Turk, PhD, RN, an associate professor in the School of Nursing at Duquesne University and author of a study published in the October 2025 issue. Despite its potential, her study, "Opportunities and Obstacles Associated With the Medicare Diabetes Prevention Program," examines the challenges of implementing the Medicare Diabetes Prevention Program (MDPP) from the perspective of program suppliers nationwide. In this conversation, Turk discusses the limited adoption of the MDPP and the inspiration behind her study. She also outlines her key findings and shares next steps for implementing and sustaining the program.

On this episode of Managed Care Cast, The American Journal of Managed Care® spoke with Gen Li, PhD, CEO and cofounder of Phesi, a clinical data company that provides AI-driven insights to sponsors and providers to optimize clinical trial efficacy. A recent analysis from Phesi found over 100 diseases currently being studied using GLP-1 RA therapies. The rapid growth of GLP-1 RA therapies being used across multiple, overlapping conditions creates an incentive for efficient and easily accessible clinical trial data to aid sponsors and researchers in establishing control cohorts using Phesi's Trial Accelerator platform and digital patient profiles.

Navigating managed vision care can be complex.  Between reimbursements, benefits, and patient expectations, finding the balance between patient satisfaction and profitability is no small feat. But what if the key isn't fighting the system, but understanding lesser-known opportunities that exist within managed care?  In this episode of Power Hour, host Eugene Shatsman sits down with Todd Lassone, Senior Manager for Strategic Partners at EssilorLuxottica, to unpack how practices can optimize their relationship with managed vision care plans. With over 30 years of industry experience — both in the exam lane and on the corporate side — Todd brings a refreshingly practical perspective on turning managed care into managed opportunity. 

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Laxmi Patel, chief strategy officer at Savista, about how the proposed federal Budget Reconciliation Act could reshape Medicaid coverage nationwide. Patel explains why states with large immigrant populations, rural hospital dependence, or provider tax funding could face the most immediate disruptions and what payers can do to prepare. Building on AJMC's prior discussion with Patel on state-level Medicaid policy changes, this conversation explores how coverage loss, care deserts, and administrative burdens may evolve if these reforms move forward—and what proactive, state-specific strategies can help mitigate the impact.

A recent case filed by the U.S. Department of Justice (DOJ) reveals how an insider was able to detect fraud in a large managed care organization (MCO).Although the topic of medical loss ratio (MLR) might be arcane to some, when the subject involves millions of dollars of potential fraud, it quickly becomes a large blip on the government's fraud detection radar.More on this topic will be reported during the next live edition of Monitor Mondays. That's when whistleblower attorney Max Voldman returns to the long-running Internet broadcast to report on how a payer, Inland Empire Health Plan, miscalculated its MLR in a scheme to rebate less money to the government than to which it was legally obligated.The weekly broadcast will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.• Legislative Update: Cate Brantley, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

On this milestone episode of Unscripted, the AMCP Podcast, they celebrate the 30th anniversary of the Journal of Managed Care & Specialty Pharmacy (JMCP). Host Susan Cantrell, AMCP CEO, is joined by Laura Happe, PharmD, MPH, Editor-in-Chief of JMCP, and Pat Gleason, PharmD, BCPS, FCCP, FAMCP, Assistant Vice President, Health Outcomes at Prime Therapeutics to reflect on the journal's evolution from its 1995 launch to today's leading voice in managed care pharmacy. Highlights include JMCP's role in shaping policy, advancing research, and tackling pressing issues such as drug pricing, equity, and access—while looking ahead to the future of pharmacy innovation and collaboration. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

Welcome back to Ozempic Weightloss Unlocked, the show that brings listeners the most current news, research, and perspectives on Ozempic, the medication that has transformed weight loss conversations everywhere.Ozempic, generically known as semaglutide, was originally approved for type two diabetes by the FDA in 2017. Its follow-up, Wegovy, hit the market in 2021 explicitly for chronic weight management. Both drugs belong to a class called glucagon-like peptide-one receptor agonists. These medications work by mimicking a naturally occurring hormone that helps the body regulate blood sugar after meals while also reducing appetite by slowing the digestive process. Many patients taking Ozempic weekly have seen impressive reductions in body weight—up to 16 percent, according to data highlighted by the American Journal of Managed Care.The popularity of Ozempic exploded when its weight loss effects were amplified on social media and through celebrity endorsements. Demand surged, and global interest grew as more people sought medical solutions outside of diet and exercise alone. But Ozempic is not just hype—it's backed by multiple clinical trials and growing medical consensus, though not without debate.Researchers continue to push the boundaries, and major updates are underway. According to Fox News Digital and the Times of India, scientists at Tufts University have developed a next-generation experimental drug aimed at delivering weight loss of up to thirty percent—nearly matching surgical outcomes but without the operation. This new compound works across four hormone pathways: GLP-1, GIP, glucagon, and peptide YY, aiming to deliver robust weight loss with fewer side effects like nausea and muscle loss. The “quadruple-action” drug is still in early preclinical stages, tested only in cells—not yet in humans or animals—but represents a bold step towards more personalized, gentle, and sustainable weight management therapies.For now, single-hormone agents like Ozempic remain widely prescribed. Experts urge those on GLP-1 medications to partner closely with their clinicians, focusing on daily protein, hydration, and resistance training to mitigate risks such as muscle loss and malnutrition. Nutritional support is key, as well as regular follow-ups.Alongside medical progress, litigation and warnings continue to surface. The Lawsuit Information Center reports that thousands of claimants have entered into multidistrict litigation over Ozempic and similar drugs, citing side effects like gastroparesis, or stomach paralysis, and rare forms of vision loss including neovascular age-related macular degeneration and optic neuropathy. A 2025 study out of the University of Toronto found semaglutide users twice as likely to develop macular degeneration compared to others—a small risk, but real and statistically significant. Another concern comes from JAMA Otolaryngology–Head & Neck Surgery, showing a possible increased risk of thyroid cancer among GLP-1 agonist users. The defense argues that many of these side effects are rare, and some findings may be linked to increased medical surveillance, rather than the drug itself. Physicians and patients are encouraged to weigh these risks alongside the benefits and always discuss options thoroughly before starting treatment.As for what comes next, listeners should keep an eye on innovations underway: oral drugs like orforglipron, combination therapies such as CagriSema, and monthly injectables from major firms—all targeting more effective weight loss with easier dosing and fewer downsides. Tirzepatide, branded as Zepbound, is currently considered one of the most potent with trial data showing up to twenty-one percent body weight loss.The obesity epidemic is far from solved, but the next wave of treatments could make weight loss less about suffering and more about smart science. Whether listeners are considering Ozempic, awaiting newer options, or just tuning in for updates, the biggest takeaway is this: work with a trusted healthcare provider, stay informed about the latest findings, and balance medication with healthy lifestyle habits.Thank you for tuning in to Ozempic Weightloss Unlocked. Do not forget to subscribe and share. This has been a Quiet Please production—for more, check out quiet please dot ai. Some great Deals https://amzn.to/49SJ3QsFor more check out http://www.quietplease.aiThis content was created in partnership and with the help of Artificial Intelligence AI

Still managing to add value for patients and payor While US markets make new highs, the S&P managed care index is half the level it was a year ago. We talk to Kevin Fischbeck about what's driven the substantial weakness and whether deterioration in medical loss ratios (MLR) is temporary or something that will last and prevent these companies from recapturing past margins. Kevin also discusses the different markets served by managed care, from commercial to Medicare Advantage to Medicaid and how profitability challenges are likely to last longer for some of these markets than for others. But he also addresses how managed care adds value to each of these settings, delivering care more effectively and cheaply than the alternatives. He notes that vertical integration is still part of the strategy at some managed care companies, and something that can still help to better align incentives, but that it's been overshadowed by challenges faced elsewhere in the business. You may also enjoy listening to the Merrill Perspectives podcast, featuring conversations on the big stories, news and trends affecting your everyday financial life.   "Bank of America" and “BofA Securities” are the marketing names for the global banking businesses and global markets businesses (which includes BofA Global Research) of Bank of America Corporation. Lending, derivatives, and other commercial banking activities are performed globally by banking affiliates of Bank of America Corporation, including Bank of America, N.A., Member FDIC. Securities, trading, research, strategic advisory, and other investment banking and markets activities are performed globally by affiliates of Bank of America Corporation, including, in the United States, BofA Securities, Inc. a registered broker-dealer and Member of FINRA and SIPC, and, in other jurisdictions, by locally registered entities. ©2025 Bank of America Corporation. All rights reserved.

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Richard A. Brook, MS, MBA, president of Better Health Worldwide, Inc., and author of a study published in the August 2025 issue. His retrospective analysis, "The Impact of Health Benefit Design on Patients With Infertility," examined how benefit design influences infertility treatment use and pregnancy outcomes. The study found that coverage for infertility treatment was associated with significantly higher use of assisted reproductive technology (ART) medications, more ART procedures performed, and improved pregnancy outcomes. In this conversation, Brook explores the current state of infertility care in the US, the inspiration behind his study, its key findings, and next steps to expand access to ART.

Breast cancer is the second most common cancer among women and the second leading cause of cancer-related deaths among women in the US. In light of Breast Cancer Research Awareness Day, the American Journal of Managed Care® breaks down the most recent advancements in breast cancer prevention, screening, and therapies.

In this episode, listen to Kelly Romo, PharmD, BCOP; and Shauna Kraft, PharmD, BCOP, share their takeaways from a live webinar on available emerging subcutaneous immunotherapy options for patients with cancer including:Basic mechanism of action and role of hyaluronidase in subcutaneous immunotherapy formulation and available dosing/schedulesAvailable pharmacodynamics/pharmacokinetics, efficacy, and safety data for subcutaneous immunotherapy formulationsCurrent and potential models for administration of subcutaneous immunotherapy in the inpatient setting and day-to-day considerationsPresenters:Kelly Romo, PharmD, BCOPManager, Oncology Medical Drug Management and Customer InitiativesBlue Cross Blue Shield MichiganDetroit, MichiganShawna Kraft, PharmD, BCOPClinical Pharmacist, SpecialistMichigan Medicine, Rogel Cancer CenterClinical Associate ProfessorUniversity of Michigan College of PharmacyAnn Arbor, MichiganResources:Consolidate your learning with a recording from an on-demand webcast, download the slides associated with this discussion, or read an expert text module or commentary on this topic. 

In this episode, listen to Kelly Romo, PharmD, BCOP; and Shauna Kraft, PharmD, BCOP, share their takeaways from a live webinar on available emerging subcutaneous immunotherapy options for patients with cancer including:Basic mechanism of action and role of hyaluronidase in subcutaneous immunotherapy formulation and available dosing/schedulesAvailable pharmacodynamics/pharmacokinetics, efficacy, and safety data for subcutaneous immunotherapy formulationsCurrent and potential models for administration of subcutaneous immunotherapy in the inpatient setting and day-to-day considerationsPresenters:Kelly Romo, PharmD, BCOPManager, Oncology Medical Drug Management and Customer InitiativesBlue Cross Blue Shield MichiganDetroit, MichiganShawna Kraft, PharmD, BCOPClinical Pharmacist, SpecialistMichigan Medicine, Rogel Cancer CenterClinical Associate ProfessorUniversity of Michigan College of PharmacyAnn Arbor, MichiganResources:Consolidate your learning with a recording from an on-demand webcast, download the slides associated with this discussion, or read an expert text module or commentary on this topic. 

Can food really be the prescription for better health? Discover how the “Food as Medicine” movement is reshaping health care and what it means for patients, providers, and the future of wellness. On this episode, special guests Noah Voreades of OLIPOP and Ivan Wasserman of Amin Wasserman Gurnani join Epstein Becker Green attorneys Jessika Tuazon and Ada Peters to explore how food is being integrated into health care to prevent and manage chronic diseases. The episode unpacks the policy priorities of Health and Human Services Secretary Robert F. Kennedy, Jr., the challenges of scaling food-based interventions, and the role of industry and government in driving innovation. Learn about the future of food as a clinical tool, the evolving regulatory landscape, and actionable takeaways for stakeholders navigating this transformative space. Visit our site for related resources and email contact information: https://www.ebglaw.com/dhc89. Subscribe for email notifications: https://www.ebglaw.com/subscribe. Visit: http://diagnosinghealthcare.com. This podcast is presented by Epstein Becker & Green, P.C. All rights are reserved. This audio recording includes information about legal issues and legal developments. Such materials are for informational purposes only and may not reflect the most current legal developments. These informational materials are not intended, and should not be taken, as legal advice on any particular set of facts or circumstances, and these materials are not a substitute for the advice of competent counsel. The content reflects the personal views and opinions of the participants. No attorney-client relationship has been created by this audio recording. This audio recording may be considered attorney advertising in some jurisdictions under the applicable law and ethical rules. The determination of the need for legal services and the choice of a lawyer are extremely important decisions and should not be based solely upon advertisements or self-proclaimed expertise. No representation is made that the quality of the legal services to be performed is greater than the quality of legal services performed by other lawyers.

Send us a textWhat happens when the demands of managed care clash with a provider's commitment to gold-standard hearing healthcare? For Jaysee Soto, owner of Altamonte Family Hearing in Florida, the answer lies in striking a delicate balance between business sustainability and patient-centered ethics.Growing up in his family's New York City bodega, Jaysee watched his parents build relationships with every customer who walked through their door. Those early lessons in community connection now form the foundation of his hearing healthcare practice, where patients aren't just customers, they're extended family. Working alongside his wife Grace, Jaysee has created a practice environment where comprehensive care is the standard, not the exception.The podcast takes us through Jaysee's unexpected journey from aspiring lawyer to passionate hearing care professional. That pivotal moment when he first witnessed a patient's face light up upon hearing their grandchild's voice clearly? It changed everything. Now he dedicates himself to creating those transformative moments for his patients, taking a full 90 minutes for comprehensive evaluations that far exceed industry minimums.But this level of care creates tension when insurance and managed care plans don't adequately compensate for best practices like real ear measurement and extensive testing. Jaysee candidly shares his approach to this industry-wide dilemma: strategically limiting managed care appointments while ensuring those patients still receive quality care, implementing service plans that bridge the gap, and planning for growth that maintains standards while increasing access.What emerges is a refreshing perspective on hearing healthcare economics. Rather than viewing patient care and business viability as opposing forces, he demonstrates how exceptional care creates its own sustainability through patient loyalty and word-of-mouth referrals. Even patients who initially come through managed care plans often return as private pay patients after experiencing the difference that comprehensive care makes.Ready to discover what ethical hearing healthcare looks like in action? Listen now and learn how leading with heart can transform both patient outcomes and practice success. Connect with the Hearing Matters Podcast TeamEmail: hearingmatterspodcast@gmail.com Instagram: @hearing_matters_podcast Twitter: @hearing_mattasFacebook: Hearing Matters Podcast

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Jonathan Gabison, MD, DABOM, and Stephen Lott, PharmD, MS. At the University of Michigan, Gabison is an obesity medicine specialist and family physician, while Lott serves as director of the postgraduate year one managed care residency program and manager of the university's prescription drug plan. Their qualitative study, "Understanding Insurance Coverage Policies for Incretin Mimetics for Weight Management," determined that the high costs associated with these therapies limit insurance coverage and contribute to variation in utilization management strategies aimed at controlling short-term spending. During the conversation, the investigators discuss how high costs, misconceptions about obesity, and inconsistent coverage policies continue to hinder equitable, patient-centered care.

Kenny White and Fred Driscoll, Alliant Healthcare, is joined by Seth Madnick, Alliant Captives, to examine how captive insurance continues to shape risk financing strategies in the managed care and ancillary healthcare sectors. The team outlines key considerations for feasibility, formation and utilization, highlighting benefits such as control over coverage terms, cost efficiency and streamlined access to reinsurance markets.

Managed Care Cast News Roundup: July 8, 2025 by Managed Care Cast

This episode recorded live at the Becker's 3rd Annual Spring Payer Issues Roundtable features Dr. Brian Smolich, Vice President, Health Alliance Quality and Managed Care Operations, Carle Health. Dr. Smolich shares how his organization is balancing cost and quality, leveraging biosimilars, digital engagement tools, and provider collaboration to improve member outcomes and transform the care experience.

This episode recorded live at the Becker's 3rd Annual Spring Payer Issues Roundtable features Dr. Brian Smolich, Vice President, Health Alliance Quality and Managed Care Operations, Carle Health. Dr. Smolich shares how his organization is balancing cost and quality, leveraging biosimilars, digital engagement tools, and provider collaboration to improve member outcomes and transform the care experience.

On this episode host Fred Goldstein invites Joe Honcz, from C4I consulting and an AMCP Board Member to discuss AI and its potential uses in Managed Care Pharmacy. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

A quick roundup episode of major news and health policy developments from The American Journal of Managed Care.

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Julia Lucaci, PharmD, MS, the senior director of global health economics and outcomes research at Becton, Dickinson and Company (BD), an international medical technology company. Her commentary, "Should Payers Incentivize Pharmacies to Blister-Package Chronic Medications?" argues that payers should consider offering higher reimbursement rates and/or preferred network status to pharmacies that dispense chronic medications in blister packs to enhance medication adherence and patient outcomes. During the conversation, Lucaci explores the widespread impact of medication nonadherence, the benefits and underutilization of blister packaging in the US, and strategies that could support broader adoption to improve chronic disease management and lower overall health care costs.

A quick roundup episode of major health policy developments, from shifting COVID-19 vaccine guidance and scientific publishing controversies to rising cancer care costs and the impact of oncology biosimilars.

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Lindsey Leininger, PhD, health policy professor and faculty director of the Center for Health Care at the Tuck School of Business at Dartmouth College, and Allister Chang, MPA, co-founder of Fabric Health, a social-impact startup that aims to improve community well-being by transforming everyday moments in laundromats into opportunities to build trust, support Medicaid recertification, and connect families with health and social services. Their study, "Unmet Health Care and Health-Related Social Needs of Laundromat Users," published in this month's issue, identifies laundromats as a promising community-based setting for Medicaid outreach, with Medicaid enrollees comprising the majority of users and facing disproportionately high levels of unmet needs. During the conversation, Leininger and Chang highlight how engaging with enrollees at laundromats can help foster trust, address unmet social needs, and strengthen Medicaid engagement.

In this Heartline Echo Episode, envision a transformative journey beyond the confines of clinical practice—a path where medical expertise converges with an entrepreneurial spirit! Join us in this week's episode with Dr. Gina Siddiqui as she discusses her passion for patient care and how it led her to become the founder and CEO of ⁠Carte Clinics⁠, a membership-based on-call physician service. Listen in as Dr. Siddiqui offers invaluable lessons that will leave you feeling inspired, informed, and empowered to pursue any business idea. There is a lot of learning that can be done independently if you follow your passion. - Dr. Gina Siddiqui Dr. Gina Siddiqui, the founder and CEO of ⁠Carte Clinics⁠ and a practicing emergency medicine physician, is a trailblazer in modernizing healthcare delivery. Her passion for reimagining the patient care experience has been showcased in pieces for the New York Times, TIME, Scientific American, and other prestigious outlets. With a background as the Chief Clinical Officer for Florence Labs and as a Clinical Leadership Fellow in the Office of Managed Care for New York City Health + Hospitals, Dr. Siddiqui's expertise and dedication to empowering innovation in the medical field are truly inspiring. In this episode, you will be able to: Discover how to navigate entrepreneurship in the medical field. Learn the importance of personalized healthcare for better patient outcomes

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/CPE/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/ZKX865. CME/MOC/CPE/AAPA/IPCE credit will be available until May 1, 2026.Taking a Step Forward in HCM Precision Medicine: Aligning Clinical and Managed Care Approaches With New Guidelines, Long-Term Evidence, and Real-World Experience In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported through an educational grant from Bristol Myers Squibb.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/CPE/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/ZKX865. CME/MOC/CPE/AAPA/IPCE credit will be available until May 1, 2026.Taking a Step Forward in HCM Precision Medicine: Aligning Clinical and Managed Care Approaches With New Guidelines, Long-Term Evidence, and Real-World Experience In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported through an educational grant from Bristol Myers Squibb.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/CPE/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/ZKX865. CME/MOC/CPE/AAPA/IPCE credit will be available until May 1, 2026.Taking a Step Forward in HCM Precision Medicine: Aligning Clinical and Managed Care Approaches With New Guidelines, Long-Term Evidence, and Real-World Experience In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported through an educational grant from Bristol Myers Squibb.Disclosure information is available at the beginning of the video presentation.

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Larragem Raines, MS, director of research at the Center for Innovation & Value Research, about her organization's open-source value model for major depressive disorder (MDD). She also defines dynamic pricing and explains how it is incorporated into the MDD value model, topics she expands upon in a recent contributor article. Looking ahead, Raines discusses the potential of artificial intelligence (AI) to improve diagnosis, treatment, and access in the MDD space.

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Brady Post, PhD, assistant professor at Northeastern University and lead author of a study published in this month's issue. His study, "Impact of Hospital-Physician Integration on Medicare Patient Mix," found no evidence that hospital-employed physicians treated a higher proportion of complex patients, at least among those enrolled in traditional Medicare. During the conversation, Post shares the inspiration behind his research, key findings, and areas for further investigation.

Today we are bringing you a conversation the use of continuous glucose monitoring technology and its transformative potential in diabetes care. Davida Kruger, a certified nurse practitioner at Henry Ford in the division of endocrinology, spoke with Jaime Murillo, MD, senior vice president and chief medical officer, medical affairs, United Health Group; Jeremy Wigginton, MD, chief medical officer at a regional Blue plan; Ian Neeland, MD, director of cardiovascular prevention, University Hospitals Harrington Health and Vascular Institute, and associate professor of medicine, Case Western Reserve University School of Medicine; and Ken Cohen, MD, executive director of translational research, Optum Health. The topics of conversation for today's podcast include how CGM addresses therapeutic inertia, enhances glycemic control, and drives improvements in patient outcomes and health care efficiency, as well as the barriers to adoption, strategies for expanding access, and the cost effectiveness of CGM implementation.

Send us a textWhen you hear "managed care" in audiology, what comes to mind? In this eye-opening conversation between Dr. Douglas Beck and Dr. Noël Crosby, the troubling reality of third-party payment systems in hearing healthcare takes center stage.Dr. Crosby, a three-time president of the Florida Academy of Audiology with decades of clinical experience, pulls back the curtain on how managed care administrators position themselves between patients, insurance companies, and audiologists – often to the detriment of comprehensive patient care. The discussion reveals how Medicare Advantage plans, now covering roughly half of all Medicare recipients, frequently fail to deliver on their marketed hearing benefits.The most concerning revelation? Many third-party payers operate under the false assumption that everyone with hearing difficulties simply needs hearing aids. This fundamentally misunderstands audiology's scope of practice. As Dr. Beck points out, approximately 26 million Americans have perfectly normal hearing thresholds but struggle with speech comprehension in noisy environments – issues that require specialized testing beyond basic screenings.Both experts share compelling insights about the limitations of "free hearing tests," the inadequacy of quick screenings, and the ethical problems with viewing every patient as a potential device sale rather than someone deserving comprehensive care. The conversation turns particularly insightful when discussing tinnitus management, highlighting how third-party payment systems often prevent patients from accessing treatments that could significantly improve their quality of life.For anyone navigating hearing healthcare, whether as a patient, provider, or caregiver, this episode provides crucial perspective on a system that often prioritizes profit over patient outcomes. The Academy of Doctors of Audiology's recent call for major reforms in hearing healthcare coverage underscores the urgency of rethinking how we value and deliver audiological services.Listen now to understand why the future of hearing healthcare depends on recognizing audiologists as healthcare providers first – not simply as hearing aid dispensers. Your hearing deserves more than a quick screening and a sales pitch.While we know all hearing aids amplify sounds to help you hear them, Starkey Genesis AI uses cutting-edge technology designed to help you understand them, too.Click here to find a provider near you and test drive Starkey Genesis AI! Connect with the Hearing Matters Podcast TeamEmail: hearingmatterspodcast@gmail.com Instagram: @hearing_matters_podcast Twitter: @hearing_mattasFacebook: Hearing Matters Podcast

Let us know what you think - send us a textAre you building a medical career… or just working in one? STOP leaving money, autonomy, and fulfillment on the table.In this episode of The Independent Physician's Blueprint, we explore how one physician broke away from the traditional medical grind and transformed a podiatry career into a thriving business—without ever being taught how in medical school. Through an engaging story of two physicians with the same name and a twist of fate, you'll uncover how business savvy, financial clarity, and managed care knowledge can reshape your medical future. You'll learn:How strategic cash flow planning can help physicians regain control and reduce stress.Why mastering the business side of medicine—IPAs, managed care, and niche specialization—can multiply your income.What it really takes to build a sustainable, burnout-resistant medical practice from the ground up.It's time to stop operating like an employee and start thinking like a physician-entrepreneur. Hit play now and learn how to reclaim your practice, your profits, and your purpose. Discover how medical graduates, junior doctors, and young physicians can navigate residency training programs, surgical residency, and locum tenens to increase income, enjoy independent practice, decrease stress, achieve financial freedom, and retire early, while maintaining patient satisfaction and exploring physician side gigs to tackle medical school loans.

While tariffs continue to dominate headlines, our Global Head of Fixed Income Research and Public Policy Strategy Michael Zezas suggests investors should also focus on the sectoral impacts of additional U.S. policy choices.----- Transcript -----Welcome to Thoughts on the Market. I'm Michael Zezas, Morgan Stanley's Global Head of Fixed Income Research and Public Policy Strategy. Today, we'll be talking about U.S. policy impacts on the market that aren't about tariffs.It's Wednesday, March 12th, at 10:30am in New York.If tariffs are dominating your attention, we sympathize. Again this week we heard the U.S. commit to raising tariffs and work out a resolution, this time all within the span of a workday. These twists and turns in the tariff path are likely to continue, but in the meantime it might make sense for investors to take some time to look away – instead focusing on some key sectoral impacts of U.S. policy choices that our Research colleagues have called out. For example, Andrew Percoco, who leads our Clean Energy Equity Research team, calls out that clean Energy stocks may be pricing in too high a probability of an Inflation Reduction Act (IRA) repeal. He cites a letter signed by 18 Republicans urging the speaker of the house to protect some of the energy tax credits in the IRA. That's a good call out, in our view. Republicans' slim majority means only a handful need to oppose a legislative action in order to block its enactment. Another example is around Managed Care companies. Erin Wright, who leads our Healthcare Services Research Effort, analyzed the impact to companies of cuts to the Medicaid program and found the impact to their sector's bottom line to be manageable. So, keeping an in-line view for the sector. We think the sector won't ultimately face this risk, as, like with the IRA, we do not expect there to be sufficient Republican votes to enact the cuts. Finally, Patrick Wood, who leads the Medtech team, caught up with a former FDA director to talk about how staffing cuts might affect the industry. In short, expect delays in approvals of new medical technologies. In particular, it seems the risk is most acute in the most cutting edge technologies, where skilled FDA staff are hard to find. Neurology and brain/computer interfaces stand out as areas of development that might slow in this market sector. All that said, if you just can't turn away from tariffs, we reiterate our guidance here: Tariffs are likely going up, even if the precise path is uncertain. And whether or not you're constructive on the goals the administration is attempting to achieve, the path to achieving them carries costs and execution risk. Our U.S. economics team's recent downgrade of the U.S. growth outlook for this and next year exemplifies this. Thanks for listening. If you enjoy the show, please leave us a review wherever you listen and share Thoughts on the Market with a friend or colleague today.

Managed Care Incentive Payment Program: Data Analytics Manager Chris Magee recaps a new LLA report that evaluates the Louisiana Department of Health's design and oversight of the Medicaid Managed Care Incentive Payment Program, which totaled $2.39 billion from September 2019 through March 2024. | https://LLA.La.gov/go/podcast

Managed Care Incentive Payment Program: Data Analytics Manager Chris Magee recaps a new LLA report that evaluates the Louisiana Department of Health's design and oversight of the Medicaid Managed Care Incentive Payment Program, which totaled $2.39 billion from September 2019 through March 2024. | https://LLA.La.gov/go/podcast

On this episode of Managed Care Cast, we speak with Arthur L. Jenkins III, MD, FACS, CEO of Jenkins NeuroSpine, to explore the intersection of advanced surgical care for sport-related neurospine injuries and managed care systems.

Every Gen X'er listening to this is gonna be singing that Clash song in your head for the rest of the day. So, let's turn our attention to Medicare Advantage policy. And on the show today, I grill the one and only Betsy Seals to find out which policies she thinks are going to stay and which are going to go. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Obviously, this is very much in the context of a new administration and also just other things that are going on. But today we talk about the following four “stay or go” policy areas. Here's the first policy area we talk about: changes and activities within the Stars program. How will the Medicare Advantage Stars program change or not? Not only with this new administration, but also there are lawsuits and how they will impact the goings-on moving forward. Second policy, will it stay or will it go, that we talk about is risk adjustment and all of the activity in government oversight and focus on recoupment of improper payments as kind of the overarching bucket and what will be the incoming administration's method around risk adjustment. This is certainly on many people's minds. The third “will it stay or will it go” policy that we discuss is the use of AI (artificial intelligence) by Medicare Advantage plans. What does the appropriate oversight of the use in AI look like? Lots of talk about those prior auth AI algorithms and the high levels of denied care. A big topic of everybody's collective mind is looking at how to ensure that oversight is appropriate and that we're using AI for good and that it's not having any adverse impact. So that's the third will it stay or will it go. Fourth, and lastly, the whole agent broker realm—additional CMS and government oversight over misleading or inaccurate information coming from the marketing or the agent broker marketing world. How will that look in 2025 and moving forward? This last one, I'm kind of all over the nuance there after reading posts and comments by Samantha George, and I would recommend following her on LinkedIn would be my suggestion. I am reflecting back on the Ann Kempski episode (EP444), where we talk about the whole, really consider the downstream impact when making any policy changes, because there can be unintended consequences. Now, in a show about carriers—in this case, Medicare Advantage carriers—I'd be pretty tone deaf not to mention the nation's ire at carriers at this exact moment in time, some of it extremely well earned and some of it reflective of an extremely dysfunctional healthcare system. I'd also be tone deaf not to mention the MedPAC (Medicare Payment Advisory Commission) report, which states that Medicare Advantage plans receive payments from CMS that are 122% of spending for similar beneficiaries in traditional Medicare. This translates to an estimated $83 billion in higher spending in 2024. And I would lastly be remiss not to mention how Medicare Advantage plans are most carriers' most profitable service lines, with average earnings of around $1800 per enrollee. All of what I said is not some kind of grand revelation, of course, to most listeners of this show. And it's also not the topic of the conversation today, although some of this did get asked and answered in the earlier shows (EP387, EP375, EP291) with Betsy Seals. One thing I will remind everyone about is that there are regional carriers that are not the big five who may or may not be doing big five types of things. And also, it is actually really difficult to run a Medicare Advantage plan successfully. They call it risk for a reason. One thing I really appreciated about the conversation with Betsy Seals that follows is her advice to contemplate value to the patient and make sure that anybody working on the carrier side, you have enough of a bead on what's actually happening to be able to identify when things are going off the rails, which does not seem to be the case in some instances. This also, by the way, having a bead on what's actually happening on the ground, helps to ensure compliance and that's piece of advice two. Last piece of advice is to learn how to be proactive and not reactive. And this is eminently more possible vis-à-vis data that's available and learning how to use it well. Betsy Seals, my guest today, has had a very busy last couple of years since she was on Relentless Health Value the last time. Betsy is CEO and co-founder of Rebellis Group, a managed care consulting firm focused specifically in Medicare Advantage. Rebellis was actually acquired in February of 2024 and joined as a family of a couple of other consulting firms that now Betsy heads up. So, in short, she's really busy. Also mentioned in this episode are Samantha George; Ann Kempski; Rebellis Group; and Vivian Ho, PhD.   You can learn more at rebellisgroup.com and alerionadvisors.com and by following Betsy on LinkedIn.   Betsy Seals is the CEO of Alerion Advisors, a family of companies dedicated to delivering unparalleled consulting services across the healthcare spectrum. As a parent organization, Alerion Advisors unites three specialized firms—Rebellis Group, Advent Advisory, and Toney Healthcare—to provide health plans and their partners with comprehensive, innovative, and results-driven solutions. With over 25 years of experience in the managed care industry, Betsy is a nationally recognized leader known for her regulatory expertise and strategic insights. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health (SDoH), and health plan operations.   05:09 Will the Star Ratings program stay in this new administration? 08:08 How will the lawsuits against CMS policies play out with this new administration? 10:24 Why is it hard for Medicare Advantage plans to survive, let alone thrive? 16:22 How does AI directly impact beneficiary lives? 21:38 What's going on now with the override payments? 27:08 How is non-collaboration going to impact Medicare beneficiaries moving forward? 31:45 Why is it important to become more technologically savvy in compliance?   You can learn more at rebellisgroup.com and alerionadvisors.com and by following Betsy on LinkedIn.   @betsyseals discusses #medicareadvantage policies on our #healthcarepodcast. #healthcare #podcast #changemanagement #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford, Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41), Andreas Mang (Encore! EP419), Dr Komal Bajaj, Cynthia Fisher    

In this episode of American Potential, host Jeff Crank welcomes Darin Selnick, a United States Air Force veteran and senior advisor for Concerned Veterans for America. Selnick shares his extensive background in healthcare and military service, discussing how these experiences shaped his role as a senior advisor to two VA secretaries and as the Veterans Affairs advisor for the president at the Domestic Policy Council during the Trump Administration. Dive into the challenges veterans face with the Department of Veterans Affairs (VA) healthcare system, including long wait times and travel difficulties. Selnick passionately argues for the importance of choice and competition in veterans' healthcare, detailing his efforts to improve electronic health records and community care delivery at the VA. Learn about Senator Marsha Blackburn's Vets Healthcare Freedom Act, aimed at normalizing the Managed Care process in the VA system and providing veterans with more freedom to choose their healthcare providers. Join us for an insightful conversation on the critical need for reform in the VA healthcare system to ensure veterans receive the quality care they deserve.   Check out American Potential here: https://americanpotential.com   Check out our Spanish episodes here: https://www.youtube.com/playlist?list=PL8wSZydeKZ6uOuFlT_1QQ53L7l6AmC83c   Facebook: https://www.facebook.com/AmericanPotentialPodcast    Instagram: https://www.instagram.com/americanpotentialpodcast/   X: https://twitter.com/AMPotentialPod