MediMedia Managed Markets
Managed Care


Pressure related in part to health care reform has encouraged narrow networks that not only help limit costs but also improve safety by promoting greater consistency and patient education, particularly with specialty products.

Medical Device Monitor
A 2.3% excise tax on medical devices could raise as much as $29 billion for the federal government over the next 10 years. Manufacturers are unlikely to pass the tax on to their customers, but may look to their suppliers to share in the burden.
News & Commentary
Hip and knee replacements are the two most common bundled procedures. Less common are bundles for attention deficit hyperactivity disorder, coronary artery bypass graft surgery, colonoscopy, congestive heart failure, developmental disabilities, perinatal care, tonsillectomy, and upper respiratory infection. One payer reports doing bundles for bariatric surgery and cataract removal, and another is doing adjuvant breast cancer and pregnancy.
News & Commentary
Cost sharing for these medications should be related to clinical value and not simply tied to what the patient pays for the medication, says a report by the Center for Value-Based Insurance Design at the University of Michigan. Instead, insurers should use more nuanced approaches to financial incentives.
Managed Care Outlook
Within five years, more than two thirds of all payments are expected to be based on measures of value, as health care moves away from the fee-for-service system. This is according to researchers at McKesson Health Solutions who interviewed executives at 114 payer and 350 provider organizations.
The Formulary Files
Krishna Rutvij Patel, Pharm D
Emerging evidence questions TRT’s long-term safety, as there are mixed data suggesting increased risk of cardiovascular (CV) events and prostate cancer. This, at a time when such therapies keep entering the market. Studies providing conflicting conclusions regarding risk of cardio-vascular events are observational studies, not large-scale long-term randomized control trials.
The Contrarians
“We don’t know for certain whether there’s cost shifting going on, but it’s unlikely that people are turning around their health status so quickly” and the savings have to come from somewhere — most likely from low-earning, and unhealthy workers. Some 50 million Americans are enrolled in such programs.
The Contrarians
Years ago, he thought for-profit insurance companies were evil. But now, “I’ve seen plenty of not-for-profit organizations behave badly, and I’ve seen for-profit entities behave well. The bigger problem is that we have a broad set of rules that don’t make any sense.”
The Contrarians
Value-based insurance design will change the conversation in health care from how much we spend to how well we spend. Fendrick says that “when you couple VBID carrot programs with VBID stick programs, you decrease access to medical services that have no proven medical benefit.”

David B. Nash, MD, MBA, the founding dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia: “I hope I live to see the day when I can come in in the morning, have my panel of patients on my office laptop, call up my registry function and there will be Dr. Nash’s performance on a population basis comparing me to my local peers, regional, and even a national peer group.”

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

Health costs could increase as much as 9% this year, according to a study of 126 insurers and/or plan administrators by Buck Consultants. “The actual increase in rates will also depend upon the underlying claim experience,” says Harvey Sobel, a Buck principal and consulting actuary who co-wrote the study.
The Wider View
Robert Royce, PhD
Sure, providers compete in the United Kingdom, but implicitly denigrating the other chaps simply isn’t done. Our correspondent in London asks: “This may keep corporate feathers unruffled, but at what cost in terms of improved responsiveness to consumers?” Doesn’t advertising help create more informed customers, or does it just muddy the waters?
The Contrarians
Despite the Affordable Care Act, we’ll still have about 31 million uninsured in 10 years and still be saddled with a system that cannot control costs, says the nationally known proponent of a single-payer system. Out-of-pocket costs, especially for cancer care, are enough to bankrupt many families.
The Contrarians
Because it has two conflicting missions, says the former IT “czar” under President George W. Bush. “Not only does it run Medicare, the biggest insurance company in the world, but also it’s a regulatory authority for the health care industry. Imagine if the Federal Communications Commission … also operated the nation’s largest cell phone company.”
The Contrarians
We could be back in the 1990s, with providers learning the hard way that they don’t know how to measure — and therefore manage — risk. ACOs hate the concept of utilization management “so much they don’t even want to admit to themselves that management of utilization is necessary.”
Tomorrow's Medicine
Thomas Morrow, MD
Eloctate allows for significantly longer time between infusions. Given that most children with severe hemophilia A receive an infusion every other day, the ability to move to a twice-per-week or even less-often infusion of a factor A is a welcomed development.
Medication Management
Thomas Reinke
Half of all insurers may not be taking advantage of rebates for drugs delivered through the medical benefit. That may change because some health plans are developing in-house capabilities to manage these drugs better, and thus preserve coverage under the medical benefit.
Contributing Voices
Krishna R. Patel, PharmD, RPh
Formulary Restrictions Blow Medication Adherence

If you haven’t already heard about the negative impact of formulary restrictions on adherence, well here it is. With mixed messages regarding formulary restrictions’ impact on patients, a recently published systematic literature review, published by Happe, et al., sought to get to the bottom this.

Thomas Reinke
The prevalence of serious behavioral and substance abuse problems among Medicaid beneficiaries is substantially higher than in the general population. Health plans succeed when they address socioeconomic factors, and the “health home” is starting to be seen as one of the best ways of managing this costly group.
Richard Mark Kirkner
Saving health care dollars requires information, and health plans are developing estimators to provide it. After all, there are increasingly more care options to choose from. But remember physician buy-in? Mostly, we are still waiting. Make sure that doctors are in the loop.