January 2013

Cover Story

In Early Diagnosis, Too, We Find That Less Is More

The United States Preventive Services Task Force has recommended against several screenings, yet health plans are finding that it’s not so easy to just drop coverage

Michael D. Dalzell

Medical Marijuana Coverage Still Lost in the Legal Weeds

While there has been movement in many states, health plans would first want to make sure that they wouldn’t be breaking any law

Peter Wehrwein

Medicare Advantage Loses Its Advantage

Extra payments of $1,200 per member per year are being eliminated as CMS seeks to increase competition among plans

Q&A

America’s Health Care Problems? The Solutions Exist. A Conversation with Mark D. Smith, MD, MBA

A new IOM report urges widespread adoption of innovations. The committee’s chair and the California HealthCare Foundation’s CEO, Mark Smith is working to make that happen.

John Marcille

Effectiveness/Efficacy Difference Too Often Ignored

Despite popular usage, these two terms mean different things, especially when coverage decisions need to be made

Ed Silverman

Why Medication Adherence Matters To Patients, Payers, Providers

A CMS demonstration program will determine whether Medicare Advantage health plans improve their quality scores by responding to bonuses that correspond with a five-point rating scale

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD ; Scott Guerin, PhD

Peer-Reviewed

The Incremental Value of Medical Nutrition Therapy in Weight Management

Overweight or obese patients who participated in a medical nutrition therapy benefit sponsored through their insurer were compared with individuals who did not participate. Outcomes, including weight change, body mass index, waist circumference, and physical exercise, were collected at baseline and 2 years later.

Donald W. Bradley, MD ; Gwen Murphy RD, PhD ; Linda G. Snetselaar, RD, PhD, LD ; Esther F. Myers, PhD, RD, FADA ; Laura G. Qualls, MHA

Editor’s Memo

Dealing With Providers Always Takes Balance
John Marcille

Legislation & Regulation

URAC and NCQA Work With Plans To Get Them Qualified for Exchanges
John Carroll

Medication Management

RA Gets First Oral Agent To Compete with Biologics

Formulary decision makers will probably be disposed favorably toward Xeljanz, the first Janus kinase inhibitor approved for rheumatoid arthritis

Thomas Reinke

Snapshot

Many practices’ EHRs might not pass muster

The Formulary Files

13% of workers pay separate drug deductibles

Plan Watch

Anthem Offers Money to Educated Consumers

The health plan’s New Hampshire subsidiary rolls out its Compass SmartShopper program to small employers this month

Frank Diamond

Tomorrow’s Medicine

Injectable Drug May Help Avoid Eye Surgery In Patients With Vitreomacular Adhesion

For many affected by vitreous degradation, surgery was the only treatment until the development of ocriplasmin

Thomas Morrow, MD

Managed Care Outlook

Medicare Advantage to remain robust this year

News & Commentary

Physician Payment Reform Will Need Insurer Assistance

News & Commentary

Acute Kidney Injuries Double Over 10 Years

News & Commentary

Preventive Care Cut In CDHP Confusion

News & Commentary

ACOs called key to doc payment reform

News & Commentary

Briefly Noted