Managed Care


Medication Management
Thomas Reinke
Rite Aid, CVS Caremark, and Walgreens are increasingly affiliating or working comprehensively with provider organizations to offer targeted medication management and chronic disease management in response to accountable care and shared-savings reform. After all, pharmacists are medication experts and many patients visit their pharmacies more often than they visit their physicians.
Thomas Reinke

Lindsay Conway

Too often, insurers focus on the medical oncology practice and do not get around to managing the full scope of services. That might be changing. Aetna, for one, is stepping up its activities to maximize cancer care in its accountable care organizations.

As pharmacies begin to look at how they will be paid for their efforts to effectively manage the growing number of specialty products under health care reform, mergers and acquisitions are accelerating in an effort to broaden resources.

Contributing Voices
Peter Wehrwein

Three more organizations have exited CMS’s Pioneer accountable care organization (ACO) program, leaving just 19 of the original 32 participants in the fold for the elite program’s third year.

The Franciscan Alliance in Indianapolis, the Genesys Physician Hospital Organization in Flint, Mich., and the Renaissance Health Network in Wayne, Pa., in the southeastern part of the state, are leaving the Pioneer program, according to a list posted on the CMS website this afternoon.

Sharp Healthcare in San Diego had announced in August that it was dropping out.

News & Commentary
The definition seems to change with the times. In the early 2000s, it was seen as a key element in the patient-centered medical care push. When the recession of 2008 hit, it became a way insurers can cut costs by encouraging patients to make better decisions. Researchers render a definition based on four stages.
Tomorrow's Medicine
Thomas Morrow, MD

Thomas Morrow, MD

The FDA can now approve therapies for serious infections as soon as it can be concluded that the benefits justify their risks. And pharmaceutical companies have responded. In early August, the FDA approved the latest, oritavancin, a semisynthetic lipoglycopeptide.
Joseph Burns

Andrew Sperling, JD

Lacking adequate care, people with mental illness often are jailed or commit suicide. Health plans can’t fix this entire problem and are reluctant to try, but they should track some interesting government programs that save money while addressing this growing public policy concern.
Larry Beresford
In this Q&A, Stephen M. Shortell, PhD, MPA, MBA, reflects on more than two decades of systems research and how to recognize real, meaningful health care integration. “For the first time, efforts to make systemic changes in payment by moving toward bundled payment and capitated payment are creating real incentives to do things differently.”
Clifford Jones
Predictive analytics might be the answer. Most health plans intervene via telephone outreach, direct mail, and face-to-face visits with providers. These approaches, argue researchers, are only moderately effective because they fail to work before a patient stops taking his or her medications.
Plan Watch
Frank Diamond

Virginia Calega, MD

The plan will stop covering power morcellation for laparoscopic hysterectomies on August 31. The move follows the well-publicized ordeal of Amy Reed, MD, whose rare and deadly cancer metastasized as a result of morcellation. Other insurers are standing back, leaving the decision to patients and providers.
Contributing Voices
Peter Wehrwein

Maybe, just maybe, accountable care organizations (ACOs) are the best bet for hitting the health care exacta of controlling costs and improving the quality of care.

Figures released by CMS on September 16 showed that the 23 organizations in the elite Pioneer program and 220 in the Shared Savings program produced over $372 million in savings while earning $445 million in shared savings payments.

Medical Homes
Timothy Kelley
Horizon Blue Cross Blue Shield of New Jersey wants to give its patient-centered medical home model extra oomph. It’s imbedding data-savvy nurses in primary care practices to reach out to high-risk patients and forestall costly crises. The insurer wants to make health care leaner, more productive, and more effective.
Legislation & Regulation
John Carroll
Even as some payers struggle to find a way to either gain a discount or steer patients to other therapies, analysts say that new competition in the hepatitis C market may not lower prices. To make matters worse, an even higher-costing Sovaldi treatment is on the way.
Cover Story
Joseph Burns

William A. Gillespie, MD

The neediest members — especially, but not exclusively, in Medicaid plans — often require more help than the services designated on a typical invoice. Helping them obtain food, transportation, housing and child care winds up costing less in the long run, some health plans discover.

David B. Nash, MD, MBA: “You give providers good information in a timely way from a reliable source that’s non-punitive about how they can improve what they do, and then give them the skills to improve, you better get out of their way because they are going to stampede to improve.”

Watch the full interview with Dr. Nash or read the edited transcript.


Private Health Insurance Exchanges Conference Washington, D.C. October 7–8, 2014
National Healthcare Facility Management Summit Palm Beach, FL October 16–17, 2014
National Healthcare CFO Summit Las Vegas, NV October 19–21, 2014
National Healthcare CXO Summit Las Vegas, NV October 19–21, 2014
Innovative Member Engagement Operations For Health Plans Las Vegas, NV October 20–21, 2014
4th Partnering With ACOs Summit Los Angeles, CA October 27–28, 2014
2014 Annual HEDIS® and Star Ratings Symposium Nashville, TN November 3–4, 2014
PCMH & Shared Savings ACO Leadership Summit Nashville, TN November 3–4, 2014
World Orphan Drug Congress Europe 2014 Brussels, Belgium November 12–14, 2014
Medicare Risk Adjustment, Revenue Management, & Star Ratings Fort Lauderdale, FL November 12–14, 2014
Healthcare Chief Medical Officer Forum Alexandria, VA November 13–14, 2014
Home Care Leadership Summit Atlanta, GA November 17–18, 2014