MediMedia Managed Markets
Managed Care



Contributing Voices
Paul Terry

One of the more audacious promises of the accountable care organization (ACO) movement is the idea that providers of medical services can play a larger role in improving a population’s health. It stems from a notion that health care financing reforms will move the focus of providers from “the tyranny of the office visit” to activities where success will be judged according to improvement in clinical metrics whether a patient visits the office or not. It’s the right vision from a health promotion advocate’s vantage point because it may serve as a preamble to an era where medical and public health practices and public policies truly intersect. Dartmouth’s Jack Wennberg famously observed predictable provider-centric small-area variation in the use of clinical procedures while the Centers for Disease Control and many other public health observers have long shown that ZIP codes have more to do with health than do medical codes. Can the next generation of health reforms reconcile the tension between these loosely related truths?

Contributing Voices
Snezana Mahon, PharmD
Snezana Mahon, PharmD

Medicare plans are furiously working to develop an optimal 2015 bid to submit to the Centers for Medicare & Medicaid Services. The pressure is especially acute this year given the rapidly consolidating and fiercely competitive Part D environment. Missteps in the bid development process have always been costly — affecting member acquisition and retention and overall profitability for the plans. But in the current environment, bid errors paired with a poor star rating will severely reduce payments from CMS and likely put plans out of business.

It’s important to understand the implications of several changes CMS proposed affecting preferred networks and enhanced alternative plans.

Contributing Voices
Steven Peskin, MD

The title of this post might also read "Don't Mess with Mother Nature"

We have seen remarkable improvements in human health as a direct result of the science that has brought us our antibiotic age with significant reductions in infant mortality, deaths due to bacterial pneumonia, and other serious infections that sometimes led to systemic infection and death.

Fast forward to today, when we may obtain with a prescription many of these powerful germ killers for $4 at WalMart and Target and drug and grocery store chains. Some retailers even give away a prescribed course of antibiotics as a loss leader to entice the customer to enter that store.

The liberal (excessive, really) use of antibiotics in the United States and much of the rest of the world is having profound unintended negative consequences.

Contributing Voices
Steven Peskin, MD
Steven Peskin, MD

Three days of a severe headache that would not respond to the ibuprofen, naproxen, or acetaminophen. "I never get headaches" is what I said multiple times to my wife and to colleagues. The morning of day three, a rash started to appear on my forehead, in the left eyebrow, in the scalp, with swelling around the left eye and swollen lymph nodes at the angle of the jaw on the left. My wife mentioned "shingles". Poor early diagnosis on my part, and, I said "Oh !*#%! that is what I have".  I was starting to feel as if I had been taken out by an NFL linebacker.

Contributing Voices
Neil Minkoff, MD
Neil Minkoff, MD

Multiple news outlets are reporting that a letter signed by Representatives Henry Waxman, Frank Pallone Jr., and Diana DeGette was sent last week to the CEO of Gilead asking for justification for the high price set on its new Hepatitis C medication, Sovaldi. (See this story.) The lawmakers also stressed that they expect Gilead to explain how the drug will get to patients in government funded programs, like Medicaid and Medicare.

Contributing Voices
Frank Diamond

Remember when many predicted that accountable care organizations (ACOs) will save health care? A study by the Health Research and Educational Trust (HRET) states that “ACOs are entities willing to be held accountable for the costs and quality of care for a defined population of patients. When the ACA [Affordable Care Act] became law, such would-be organizations were likened by some observers to unicorns — they exist in our imagination, but no one has actually seen one.” (Certainly not Regina Herzlinger, PhD, as we reported here.)

Harsh, perhaps, but a recent study by the Centers for Disease Control and Prevention searched in vain for the cost savings in Medicare ACO pilots. The HRET says that “only 25% of physician practices have joined or formed ACOs, and another 15% plan to do so.”

Contributing Voices
Paul Terry

Recently a Minnesota school was evacuated after 10 students got sick during choir practice. A carbon monoxide leak was the presumed cause, given the similarity of student’s symptoms and the rapid spread of complaints. Thirty students in all were taken to the hospital and the school was closed for the day. Tests proved negative, recovery was quick, and the Minnesota Department of Health (MDH) now reports that the likely cause was psychogenic illness.

The state spokesman said that when people in a group become ill at the same time with subjective complaints, “It is no less real.”

It seems that when an affliction — real or imagined — hits, it can spread quickly among some people. According to one of the more recent CBS News Poll, 61% of Americans disapprove of how the ACA rollout is being handled. Nevertheless more Americans are in favor of fixing the law (48%) or keeping it as is (7%) than repealing the ACA altogether (43%). More telling perhaps, according to several opinion polls about the ACA since 2010, is the stability of opinions concerning Americans’ support for or opposition to the law.

Only time will tell whether the latest ACA anguish from the chorus will fade without treatment, but one thing seems increasingly obvious: Debates about the ACA are distracting from the inertia needed for additional reforms if we are serious about reducing health care costs and improving the health of the nation.

Contributing Voices
Neil Minkoff, MD

Germany is the third biggest drug market in the world, with $42 billion spent on pharma products in 2012. Germany allows its insurers to work together to negotiate with pharmaceutical companies to create one price for all Germans. There’s the official list price, which is made public, and the proprietary discounted price. The German public price list is used widely in Europe and Japan for drug pricing and negotiations.

The German government is looking to make the discounts public knowledge as well. This is designed to reduce margins for suppliers and pharmacies, so that they base their margins off of the true prices, rather than list. The pharmaceutical companies are concerned that the release of the discounts will eat into their revenue from the other countries that use the current public list, which seems to me to be tacit admission that the discounts offered elsewhere aren’t as aggressive as the ones Germany’s pooled insurers can get.

This comes after the aggressive actions of Germany’s Institute for Quality and Efficiency in Healthcare, which is the equivalent of Britain's National Institute for Health and Care Excellence (NICE). They’ve been aggressive about looking for deeper value before allowing products access to the German market, which seems largely cost driven.

My concern is how this affects the U. S. market.

It is widely believed that the American health care system subsidizes the markets where access is more limited and prices are set. For example, Britain just worked with pharms to hold the NHS spend on brand drugs flat over the next two years, so growth in that market is limited. The pharma companies' need for growth means that they will be raising prices elsewhere to support flat trend in the UK.

That why it seem inevitable to me that the US government will step in. The global pharma market is far from free. It is a messy amalgam of single-payer, third party payers, supplemental plans, private insurers and the U.S. Centers for Medicare & Medicaid Services. As health care costs continue to rise in the U.S. a convenient target will be drugs that are available in other countries for a fraction of the American price.

Neil Minkoff, MD, is medical director of MediMedia Managed Markets and also an independent health care consultant

Contributing Voices
Steven Peskin, MD

"Welcome to Moe's"  is the warm and friendly greeting of the staff at one of my favorite cantinas — Moe's Southwest Grill, where a rice bowl and iced tea set me back just $9 and change. But for one woman who underwent Mohs surgery for a very minor lesion that may not have required the Mohs procedure and the subsequent plastic surgery repair, her bill for the day was over $25,000, as reported in a January 18, 2014 New York Times article titled "Patients' Costs Skyrocket; Specialists' Incomes Soar".

In the article, the Times journalist Elizabeth Rosenthal notes:

"Use of the surgery has skyrocketed in the United States — over 400 percent in a little over a decade — to the point that last summer Medicare put it at the top of its “potentially misvalued” list of overused or overpriced procedures. Even the American Academy of Dermatology agrees that the surgery is sometimes used inappropriately"

In this instance, the patient, a professor at the University of Central Arkansas, pushed back on the $25,000-plus charges, and, after months of wrangling, Baptist Health Medical Center reduced the bill to around $5,000, with the largest component of the reduction being the plastic surgeon's fee -- from $14,407 to $1,375 (Still a nice paycheck for what was likely less than an hour of time!).

The patient subsequently went to a dermatologist at the University of Arkansas who said that she likely did not need "such an extensive procedure." The patient's final comment in the article: "It was like, "Take your purse out, we're robbing you'"

Welcome to Mohs!

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, and is governor of the American College of Physicians, New Jersey South.

Contributing Voices
Craig Keyes, MD, MBA

I once had a patient with HIV who refused to take his medication. His noncompliance was not because he lacked information about his illness or because he didn’t understand why it was important to take his medications. He knew full well that he would die without taking them.

After doing a little digging, I learned that the reason was personal. He was afraid to tell his partner about his diagnosis. Not only was he afraid to admit that he had been unfaithful, he worried that his partner would leave him. My experience with this patient was a valuable lesson for me that medicine is not what I thought it was.

I realized that the practice of medicine is not just about a series of clinical decisions based on evidence-based practices. It is also about helping people to change their behaviors, whether they need to take their meds, lose weight, or quit smoking. If we want to achieve optimal outcomes, then it is part of our job as care providers to help people identify and address personal barriers to healthy behavior change.



Pharmaceutical Pricing and Contracting Conference Philadelphia, PA September 22–23, 2014
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