Managed Care


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.

Focus on Biologics
Katherine T. Adams

Rebecca Bechhold, MD

This is a problem with all medications, but especially so for these new products that are expensive and require following a strict schedule. Patients also, for the most part, don’t like injecting themselves, and will often abandon the regimen once they feel better.
The Formulary Files
Krishna Rutvij Patel, PharmD
Money saved up front through tight formulary management, might be spent several times over later because of poor outcomes that will boost overall costs, say researchers. Nighty-three studies having a total of 292 outcomes are included in this analysis.
News & Commentary
It comes down to portability. Employees with HSAs can roll the money over from year to year, and also take it with them when they leave a job. Not so with health reimbursement arrangements (HRAs). HSAs have the added benefit of driving more employees to wellness programs.

F. Randy Vogenberg, PhD, RPh: Contrary to its intent, the Affordable Care Act has decreased access to primary care physicians while at the same time reducing support for the education of new doctors who could help relieve that problem.

Legislation & Regulation
John Carroll

Tim Elenz

To take advantage of the prospects associated with the Affordable Care Act, a broker has to learn the many new and pending regulations. They often end up working a lot harder for less money, but some are educating themselves and are actually doing better.
Biologics in Development
Katherine T. Adams
Conflicting findings from the huge phase 3 ALTTO trial and the NeoALTTO trial, the neoadjuvant counterpart to ALTTO, stole the spotlight at the annual meeting of the American Society of Clinical Oncology.


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