For the first time, the share of workers with employer-sponsored coverage who are enrolled in HMOs or point-of-service plans is falling, according to a William M. Mercer Inc. survey. Half of all covered employees in 1997 were enrolled in HMOs or POS plans, but that dropped to 47 percent last year. PPOs' share, meanwhile, grew from 35 to 40 percent.... Another first: Inpatient days per 1,000 HMO enrollees increased in 1997 to 255, up from 246 in 1996, says Maryland-based HCIA Inc.... HMOs will fund patient care in some National Institutes of Health-sponsored clinical trials, under an agreement brokered by NIH and the American Association of Health Plans.... The Health Care Financing Administration will now give Medicare beneficiaries specific reasons for denials of claims. No longer will HCFA use the term "not medically necessary." ... The California Medical Association sued FPA Medical Management, alleging breach of fiduciary duty. CMA says the bankrupt PPM owes physicians millions in unpaid claims.... The New Mexico Medical Society is trying to figure out what to do about physicians deserting the state, attracted to bigger paychecks in Texas. The AMA says New Mexico lost an average of 27 physicians a month in 1998, up from 18 per month in 1997.
House Republicans come out with their ACA alternative. A continuous coverage surcharge replaces the individual mandate. But where’s the CBO score?
The biosimilar segment of the pharmaceutical industry is on fire. Some 700 biosimilars are at some stage of development, and more than 660 companies are involved in some way in the biosimilars land rush. Still, only a handful may get on the market in the next few years.
No one knows how much of an effect biosimilars will have on oncology expenditures. Pricing and market share are in a large, opaque “to be determined” cloud. But there’s certainly potential for a major impact that could lower oncology expenditures by millions, if not billions.
The future of biosimilars in this country is nothing if not uncertain. Most immediately, the U.S. Supreme Court is hearing a case that will determine the timing of the 180-day waiting period before a biosimilar can go on the market. But there are larger and longer-term issues at play as well.
While coupons help individual consumers, they are also having a major impact on the insurance industry and anyone responsible for paying health care bills. Insurers and pharmacy benefit managers complain that they foil formularies and other pricing strategies designed to steer consumers to less-expensive drugs.
The hard truth is that telehealth’s future—its size, its contours—will depend a lot on what payers will be willing to pay for. Currently, commercial plans cover only a limited number of services. In addition, research suggests that there may be quality and utilization problems.
Insurers should consider covering new drug-delivery devices that can improve outcomes while lowering disease-specific pharmacy and long-term overall health care costs. Managing these devices in the pharmacy benefit will consolidate volume-based purchasing and capitalize on PBM strategies for improving adherence.
Basaglar is coming on the scene during tumultuous times for insulin products. Manufacturers are under attack for price hikes. There are allegations of backroom rebate deals. And a class-action lawsuit has been brought on behalf of uninsured patients, charging insulin makers with setting artificially high prices.
Evaluating the quality of telemedicine care is about as easy as evaluating the quality of health care, period, and researchers are still ironing out the methodological kinks. That may be one reason research results are all over the place. This article involved reviewing nine such studies, and the findings are a mixed bag.
The results can be tragic. Patients with addictions are unlikely to wait the hours or days it takes health insurers to approve the medications they need. Insurers are changing their practices, but not without some outside pressure.