November 2011

Cover Story

Will ‘Essential Benefits’ Break the Bank?
The size of the essential benefits package may determine whether insurers can operate in the highly regulated exchange market. Expect strong lobbying from health care interest groups.

Michael D. Dalzell

PSA Fails the Test, but Does It Matter?
Clinical executives at health plans want to see how providers react to draft recommendation against procedure

Frank Diamond

Insurers Move Toward More Equitable Care For LGBT Population
Discrimination persists in many areas, but slow progress is being made

Joseph Burns

Q&A

A Conversation with Mary Barton, MD, MPP: Keeping Measurement Relevant
With national attention on health care reform and new models of care, the NCQA’s VP for performance measurement looks at how quality improvement can stay at the forefront

John Marcille

Peer-Reviewed

Strategies for Measuring Outcomes and ROI for Managed Care Programs
Determining return on investment and improvement of outcomes is essential when new programs are being tried, but the research method must be chosen carefully

Andrew Kolbasovsky, PsyD, MBA

Editor’s Memo

Jobs’s Death Offers Lesson About Importance of Data

John Marcille

Legislation & Regulation

Health Plans Frustrated by Spate of Drug Shortages
The gray market, where medications can be repriced, is becoming unmanageable

John Carroll

Medication Management

New Technology Makes Oncology Pathways More Flexible
Decision support tools provide new options for oncologists and health plans

Thomas Reinke

Compensation Monitor

Fewer annual incentive programs offered to docs
The Formulary Files

Making a list and checking it twice
Plan Watch

Mandatory Imaging Program Takes Aim at Overutilization
Holding physicians to best-practice guidelines with the threat of refusing to pay for unnecessary tests reaps dividends

Frank Diamond

Tomorrow’s Medicine

Insurers Will Find Icatibant Lifesaving but Expensive Treatment
Managed care once again faces the all-too-familiar debate about cost and benefit

Thomas Morrow, MD

Managed Care Outlook

Patent cliff: Billions to be saved — starting now
Lipitor led the way, and other blockbusters are following



News & Commentary

PPOs Make Gains in Quality

Insurers Need to Ensure IT Readiness for ICD-10

Managed Medicaid’s Workability Probed

C-Section Guide Seems to Be Flawed

Headlines on Deadline…