More on the pay-for-performance push. MedVantage, a consulting company, says that more such programs (42 percent) are now aimed at specialty care. But physicians are wary. "There are a lot of established markers for quality care in our specialty, but often even in those, there is disagreement," Ronald Vender, MD, a partner at the Gastroenterology Center of Connecticut, tells the Wall Street Journal.... The nation's HMOs operated on a slim profit margin in the first three months of 2004, according to Weiss Ratings. This, despite the fact that they reported $3 billion in profit, representing a $742 million increase over the $2.3 billion the companies earned for the same period in 2003. "Although the industry has enjoyed an increase in revenues by raising premiums, insurers have also had to deal with the rising cost of medical care as a result of more open networks, an aging population, expensive medical advances, and an inefficient health care system," says Melissa Gannon, Weiss's vice president.... Health coverage is not a factor in determining the level of care children ages four months to 35 months receive in the U.S., according to a study in December issue of Pediatrics. Neither is race, ethnicity, or income. Then why, according to the study, is one-third of that population not getting the preventive care it needs? "I think, frankly, [providers] are not doing the kind of job they should be doing," Barry Zuckerman, MD, chief of pediatrics at Boston Medical Center, tells the Boston Herald.... CMS has selected the 26 regions of the country where Medicare Advantage will offer PPOs. It also unveiled last month the 34 regions where private drug coverage will be offered to beneficiaries. The reaction of health plan officials, who wanted more regions, was mixed. Karen Ignagni, president and CEO of America's Health Insurance Plans, appreciated that CMS "really worked hard" to come up with the plan. Alissa Fox, policy director for Blue Cross and Blue Shield Association, said that "This makes it more difficult for the Blues plans."
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.
If millions of Americans lose Medicaid or private health insurance coverage because of the unACAing of American health care, telehealth may seem like a gimmicky sideshow rather than a good-faith effort to bring health care into the digital century.