Managed Care
News & Commentary
Spending on ambulatory care rose by 23.5% between 2007 and 2013, according to the Census Bureau. Physician offices earned about $405 billion from ambulatory care in 2012, up 20.6% from the approximately $336 billion earned in 2007. The ambulatory workforce also grew about 15% in the same period.
News & Commentary
The use of CTs and MRIs in the workup for headaches more than doubled between 1999–2000 and 2009–2010. During the same period, physicians were less likely to go the less expensive and guideline-driven route of giving patients lifestyle advice on how to deal with the problem.
News & Commentary
The risk of newborns with jaundice getting a rare form of cerebral palsy are virtually nil, if guidelines developed by the American Academy of Pediatrics are followed, says a study in JAMA. In fact, present guidelines may be too stringent, according to researchers at UCSF Benioff Children’s Hospital San Francisco.
Contributing Voices
Peter Wehrwein

If you're into health care policy and law, tomorrow is your Superbowl, World Series, and World Cup all rolled into one.  

Oral arguments for King v. Burwell are scheduled to start tomorrow at 10 a.m. As Richard Mark Kirkner explained in our February issue, the case could uphold the ACA or severely crimp the law by eliminating premium subsidies in the 34 states that use the federal health exchange.

The ACA has been resilient, and many health care interests would rather live with the law, despite its flaws, than see it come undone.

Biologics in Development
Katherine T. Adams
Hallucinations and delusions are common in people living with Parkinson’s disease, but many antipsychotic drugs are either ineffective or worsen motor symptoms. With phase 3 testing of pimavanserin (Nuplazid) completed, Acadia Pharmaceuticals hopes to change that. It could have the drug on the market by the end of this year.
Michael D. Dalzell

Rishi Agrawal, MD

CMS now pays for developing a care management plan for patients with chronic conditions. When it comes to compliance with regulations governing payment, however, providers are long on uncertainty and CMS is short on guidance. Problems with EHRs and costs to the patient may compromise the regulation’s effectiveness.
News & Commentary
In 2011, 48% of new MA enrollees were new to Medicare and 52% had switched out of the traditional program, according to Kaiser Family Foundation researchers. In past years, a greater percentage came from those who switched from the traditional program.
News & Commentary
Physicians have until February 28 to attest that they’ve met the 17 core requirements for stage 2 for their Medicare and/or Medicaid patients. As of early December, however, only 3,655 eligible providers were paid for implementing stage 2, compared to 268,686 paid for stage 1.
Electronic health records (EHR) cannot stand alone, say researchers in a PwC report. While the number of providers integrating smartphones and tablets into their EHR collection system has risen, there's still a long way to go. More patients want to see this, however, and doctors who want to stay competitive will respond.
Medication Management
Thomas Reinke

Cheryl Larson

Consumer directed health plans (CDHPs) have moved out of the shadows of PPO and HMO plans and into the forefront of employer strategies for health care benefits. Employers need to be more attuned to the longer range cost implications of their CDHP offerings so that employees can pay for their medications.
Frank Diamond

Alan Muney, MD

When the relentless climb in health care spending began to level off in 2002, few experts predicted that we may have turned a corner because economists, to this day, can’t agree on what caused the downturn. Not only does the deceleration continue, but we may eventually talk of decreasing costs.
Cover Story
Joseph Burns

Lisa Guertin

Money really does talk. Some health plans pay beneficiaries anywhere from $10 to $150 or more to pick low-cost hospitals, imaging centers, infusion sites, clinical laboratories, and other care providers. It seems to be a win-win. The more insurers save, the more financial incentives they give out.
Contributing Voices
Peter Wehrwein

Last May, two health advocacy groups filed a complaint with the Office for Civil Rights at HHS accusing four insurers selling plans in Florida of discriminating against people with HIV/AIDS by putting the drugs for treating the condition on the top tier of their formularies.

Researchers at the Harvard School of Public Health have followed up that complaint with their own research into what they are calling “adverse tiering.” The researchers, Douglas B. Jacobs and Benjamin D. Sommers, reported their results in this week’s New England Journal of Medicine.

The Harvard researchers looked at silver-level plans listed in the federal health exchange in 12 states, six with insurers mentioned in the complaint (Delaware, Florida, Louisiana, Michigan, South Carolina, and Utah) and six of the most populous states without any of those insurers (Illinois, New Jersey, Ohio, Pennsylvania, Texas, and Virginia).