Andrea Caballero

2023 Health Plan User Groups: No dog and pony shows allowed

January 23, 2023

Granted, most HPUG meetings veer more toward “engaged conversation” than “heated debate” but this is how CPR moves the Overton Window. CPR members don’t just ask health plans for updates on how many dollars they’ve dedicated to their bundled payment program: we push them to respond to tough questions in new territory like data sharing, health equity and their post-COVID payment reform strategies. We make them all take the same test through our program evaluation tools so they can’t cherry-pick statistics or hide behind shiny marketing materials. And because CPR members set the agenda for the HPUG meetings, the discussions focus on what matters most to you, purchasers, and what keeps you up at night. It’s OK if the health plans squirm a little; it’s what helps them grow.

Whatever we’re doing, it’s not working: The Case for State Policy Intervention in Health Care, as told through a parable about toddlers and swimming lessons

January 9, 2023

younger daughter Dylan was three, she emphatically declared that she hated swimming lessons. Unfortunately for her, she has a mother (me) who believes with equal conviction that learning to swim is a safety issue and therefore non-negotiable. Thus, Dylan and I were at an impasse, except that one of us (me) believed that she could convince the other (Dylan) to relent through a combination of authority and influence (and also bribery). One afternoon at our local pool, I found myself pleading, cajoling, promising sweets and screen time (and threatening their removal), if Dylan would just allow me to help her into her bathing suit. “You don’t even have to go in the water!” I lied. Dylan didn’t buy it and was expressing her mistrust in a 9-alarm screaming toddler melt-down. It was at that moment that another woman – likely old enough to have grown children of her own – paused and offered the following counsel: whatever you’re trying to do, she said, it isn’t working.

Is Payment Reform Exiting a 2+Year Shelter-in-Place?

November 14, 2022

The pandemic stimulated significant uncertainty about the future of payment reform. After all, payment reform is a disruptive strategy, requiring providers to modify practice patterns and payers to negotiate measures of performance by which providers are held accountable for care quality. The early days of the pandemic were a time during which pushing payers and providers on payment reform could have been viewed as being out of touch with the magnitude of the situation. The pandemic created a pause and stimulated leaders to rethink the potential of payment reform. For example, we pondered whether hybrid capitation/fee-for-service would gain momentum as a means for primary care providers to receive guaranteed revenue. And we continue to ponder it, because frankly, our $4+ trillion health care system doesn’t turn on a dime. CPR has been and remains in the

I decided to shop knee surgery in the San Francisco Bay Area, using the Sage Transparency tool. Here’s what I found…

July 18, 2022

In full disclosure, at the moment, I (thankfully) do not need knee surgery. But I might easily need it someday. I run a lot, my neighborhood is very hilly, and

Is it Time to Throw the Book at the Health Care Market?

May 23, 2022

Purchasers, brace yourselves for a radical idea: the time has come for state governments to restore balance, competition and affordability to health care markets. Recognizing that regulation is usually considered

Are there surprises with the implementation of the No Surprises Act?

September 13, 2021

Getting these details right will determine if implementation of the No Surprises Act will not only protect patients from most high and unexpected medical costs but also help reduce the need for balance billing in the first place and keep prices in check.

Got hospital “lemons” in your network? Ditch them or make lemon-“aid”?

August 24, 2021

Back in October 2019, we published a blog post on the challenges of building a high-performance network (HPN). We landed on the conclusion that an HPN should be designed with sensitivity to

Fearsome Beast or Toothless Tiger? A look at the Hospital Price Transparency Rules

August 2, 2021

Will the updated penalties and clarifications proposed by CMS compel hospitals into compliance? The jury is out, but the impact of the proposed updated rules depends heavily on enforcement.

Go Ahead, Ask us Anything… About Reference-Based Pricing

May 25, 2021

When the RBP vendor and provider “agree” on a rate, who pays the difference? The RBP vendor or the employer? It depends – and the outcome will likely be reflected in the vendor’s administrative fee.

Reference-based pricing: 3 models that cut health care cost inflation at its roots

April 12, 2021

Employers and consumers are eager for solutions that attack health care cost inflation at its root cause. One prominent strategy is using reference-based pricing (RBP) models that anchor commercial rates to Medicare, or some other rationalized external benchmark. Like so many health care innovations, reference-based frameworks encompass multiple branching models, and as such the term “RBP” has come to mean different things to different stakeholders.

Any Way the Wind Blows: The Future of Heath Care Payment Reform

January 19, 2021

A tornado is what comes to mind when thinking about the future of alternative payment models (APMs). It’s not because the health care ecosystem (let alone APMs) are poised to wreak horrific destruction upon us all. Rather, the tornado analogy derives from the powerful and influential forces blowing the APM movement in multiple and conflicting directions.

It’s harvest season: What are purchasers reaping from their network strategies?

October 12, 2020

Would 2020 be the year that health care purchasers finally abandon broad PPO networks in favor of curated solutions like narrow, tiered or high-performance networks? Julianne McGarry review’s KFF’s 2020 Employer Health Benefits Survey to find out.

The Great Delivery System Shake-Up

August 11, 2020

“What I see now is confusion, disorientation, uncertainty, and anxiety. That creates an opportunity, but it doesn’t provide a direction.” – David Blumenthal, President of The Commonwealth Fund, speaking at

If you’re playing without a REF, you can’t trust the scoreboard

June 22, 2020

Introducing new tools from CPR to standardize the evaluations of Centers of Excellence, High Performance Networks, Reference Based Pricing programs, Bundled Payments. Each tool is tailored to measure relevant program performance in terms of cost of care savings, quality outcomes, changes in utilization, and member experience.