Richard Mark Kirkner

In their decision to uphold tax subsidies for policies sold on the federal health insurance exchange established by the Affordable Care Act (ACA), the Supreme Court Justices showed a keen understanding of the history of various state health reform measures and how insurance markets operate in general, invoking terms like community rating, adverse selection and death spiral.

Norman S. Ryan MD

Estimates show that 64% of the Medicare population and 72% of commercial and Medicaid plans have at least one care gap. We know that care gap reductions can lead to improved health outcomes and increased patient satisfaction, which can, in turn, improve quality measures.

Implementation of health management programs is helping health plans improve scores in the prevention, chronic condition management, and patient satisfaction categories, but overall improvement is highly dependent on engaged and satisfied members.

While there are two primary goals of disease management programs—to educate and inform and to motivate behavior change—the traditional model focuses more on the former and less on the latter.

If motivation and behavior rarely become the focus of systematic intervention, then it will be difficult for members to do their part in closing their own care gaps. What results is what we often see—a less meaningful impact on members’ health, healthcare utilization, and healthcare cost reduction.

If health outcomes are going to improve, members need help with changing behaviors.

Ted Slafsky

Contrary to the highly misleading picture painted by critics, the 340B drug discount program is working as Congress intended and helping millions of underserved Americans receive better healthcare every year.

The pharmaceutical industry has gone to great lengths to misconstrue how the program functions in an effort to vilify safety-net hospitals. These are the urban and rural facilities across the country that care for all patients, regardless of their ability to pay.

Frank Diamond

They are relatively cheap to develop, since clinical trials are small and “the lack of alternative treatments give orphan agents an advantage when up for regulatory review,” according to a report by Evaluate, a life science market intelligence company that provides forecasts on that sector. The company’s second annual EvaluatePharma Orphan Drug Report says that orphan drug sales will make up 19% of prescription drug sales by 2020, totaling about $176 billion.

Norm Ryan, MD
Norm Ryan, MD

As the healthcare industry continues the shift toward value-based medicine, Medicaid plans and providers have two clear avenues to pursue in demonstrating success in managed care and population health that can improve their HEDIS scores:

John Marcille

I have been seeing reports from the Workers Compensation Research Institute (WCRI) about physicians dispensing drugs. That this practice still exists surprises and dismays me.

I lived much of my life in New York State, where I had never encountered the practice. I became aware of it only when I was working for a publication that catered to primary care doctors, and of course I thought that it was a great idea because of the convenience.

Steven R. Peskin, MD, MBA, FACP

“At first they thought it was anxiety,” Melissa Thomason began her deeply moving and inspirational story.  Melissa’s first pregnancy was complicated by preeclampsia, requiring delivery 5 weeks early by C-section. Her elation was short-lived when she experienced “a bulldozer sitting on her chest and shortness of breath” two hours after her Cesarean delivery. She was told that anxiety is frequent after child birth.

“Thankfully, my OB listened to me and ordered a CT scan of my chest.” A nightmare: The severe pressure, pain and shortness of breath were caused by ...

Edie Castello
CEO, eQHealth Solutions

Technology in health care is in danger of going the way of the home exercise bike: Lots of potential, not enough use — and less-than-optimal results.


Take data analytics, for example. With more health care organizations than ever before using electronic health records, we’re finally getting what we have been asking for: A plethora of really good data that could inform decision making. In 2011, data from the U.S. health care system reached 150 exabytes. As growth continues, big data for U.S. health care will soon reach the zettabyte (1021 gigabytes) scale and ...

John Marcille

Anyone who spends much time talking with me knows that one of my concerns, and not just as an editor, is the misuse of language by people in health care. Yes, I have a list of examples, and I might share that in a future essay. Today, we'll consider just one problem.

You'll be hearing and using the terms EMR (electronic medical record) and EHR (electronic health record) more and more. But will you use them correctly? Are they interchangeable? I myself have confused the two. In fact, I used EMR wrongly in an interview the other day and the subject didn't bat an eye, even though his reply assumed a meaning for EMR that is not the real meaning. So it's easy to do.

Norman S. Ryan, MD
Norman S. Ryan, MD

As if the worsening diabetes epidemic were not enough to worry about, this chronic condition also increases risk for complications like heart disease, stroke, and kidney failure. This is a major challenge for health plans managing the care of a growing population of Medicaid members, who tend to overutilize emergency rooms for routine or non-urgent care.

While preventive and disease management programs are helping improve outcomes for people with diabetes and other chronic conditions, more must be done beyond just phone outreach to adequately engage Medicaid members. For instance, the single mother with young children and no car doesn’t need a call to remind her of an A1C test; she needs help resolving socioeconomic barriers like lack of transportation or child care.

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Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.