Two of the most powerful movers and shakers in managed care have left their jobs. Charles “Chip” Kahn, regarded as one of the most knowledgeable health care experts on Capitol Hill, resigned as majority staff director of the House Ways and Means Subcommittee on Health to become chief operating officer and president-elect of the Health … Read more

Picture this: Fearing the worst, a 57-year-old man with chest pain goes to the nearest emergency department, where a physician orders a diagnostic workup. The final diagnosis: dyspepsia. Fortunately, this patient is insured, so the cost of the workup (which could be as high as $500) will be covered. Or will it? Several times a … Read more

A bill before the Georgia legislature that would allow patients to sue HMOs for malpractice has created an unusual alliance between physicians and plaintiffs’ lawyers, both of whom support the measure. Health plans and business groups oppose the bill, which the Georgia Chamber of Commerce calls a “huge threat” to employers. The legislation would hold … Read more

Gastric adenocarcinomas are basically named cardia and non-cardia dependent on their anatomic site. Malignancies of the gastric cardia emerge in the locale bordering the esophageal-gastric intersection and in this manner share epidemiological qualities with esophageal adenocarcinoma (EAC). Non-cardia malignancy, otherwise called distal stomach disease, is more normal and emerges in the lower bit of the … Read more

The Medical Group Management Association surveyed 960 member practices to gauge compensation trends. Gross charges — which are the charges, at undiscounted rates, of all services provided (or productivity) — for all primary care physician categories increased slightly (0.4 percent) in 2000 compared with the 11.6 percent increase in 1999. This is the first time … Read more

ohn Marcille The symbiotic relationship between insurer and provider has often made an unexpected turn or unforeseen detour. One new influence points this way, another that way, and who can blame insurers who pause before proceeding? Our cover story examines the recent work of the United States Preventive Services Task Force. As contributing editor Michael D. … Read more

Larry Boress President and CEO of the Midwest Business Group on Health In their relationships with vendors, employers all too often don’t set expectations for levels of service, adequacy of reports, or how performance will be measured. They are often left with the performance deemed appropriate by the vendor, which may not satisfy them or … Read more

Thanks to lower-than-anticipated spending for Medicare, national health expenses will grow more slowly in the coming decade than previously thought. Still, the nation’s health care bill is expected to double to nearly $2.2 trillion by 2008.$2.2 trillion by 2008. The Health Care Financing Administration predicts that Medicare spending will rise only 4.5 percent from 1997 … Read more

Not too long ago, retail health clinics were viewed with wariness—and worse—by other health care players. Now their value is recognized. Richard Mark Kirkner inShare Tweet Widget (link is external) The low cost and easy access of the “doc-in-a-box” concept has been well documented. Where once someone with an ear infection or bad case of … Read more

BY JOHN LA PUMA, M.D. A colleague in a Southern state writes: “A 35-year-old woman is paralyzed from C3 [the third cervical vertebra] down secondary to a CVA [cerebrovascular accident, or stroke], and has a tracheostomy and a portable ventilator. The HMO says that she is “custodial care” (not a covered benefit), wants to delegate … Read more

Fifty-nine percent of prescriptions for mental health medications are written by family physicians, not mental health specialists, which raises concern about the quality of some treat ments, a new study indicates. The research, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) and Thomson Reuters, examined 472 million prescriptions written for psychotropic drugs … Read more

Safety and medical effectiveness most determine whether a health plan will cover a new drug, according to a study in the March/April Health Affairs. Supported by the U.S. Agency for Healthcare Research and Quality, researchers polled chief medical officers or pharmacy managers at 53 plans. The conclusions counter popular belief that price drives plans’ coverage … Read more

This month I want to share with you some late-breaking news about upcoming changes to the Stark law that affect all physicians and, indirectly, most other providers. The Omnibus Budget Reconciliation Act of 1989 (“Stark I”) disallowed physician referral of Medicare patients to clinical laboratories in which the physicians or members of their families had … Read more

Health plans hope to rein in utilization by raising pharmacy copayments. Whether the scheme works or backfires depends on how it’s implemented. With PPO enrollment nearing 100 million, HMOs are getting a healthy dose of competition. Is the PPO here to stay — or just a temporary distraction? Michael D. Dalzell Senior Editor A few … Read more

That criticized Sen. Jeff Sessions (RALA.) , the nominee for attorney general.Opposing Sessions’s ill-fated nomination to a federal judgeship at 1986. King’s letter Sessions of racial bias; Kennedy’s called him a”disgrace into the Justice Department.”The mechanics used to quiet Warren is popularly referred to as Rule 19, an arcane and seldom invoked provision in the … Read more

It is often an on-again, off-again disease, distressing partly because it is so un­predictable. It may defy the conventional wisdom about adherence and early treatment. And escalating prices have undercut cost-effectiveness arguments for the drugs that can keep it in check. Multiple sclerosis is a managed care nightmare. The disease doesn’t have a cure, the … Read more

At last, there’s a biosimilar-like competitor in the U.S. insulin market. Can Basaglar put some downward pressure on prices? In December, Eli Lilly and Boehringer Ingelheim became proud parents, launching a new insulin product into the world. They dubbed it Basaglar, and it bore a striking resemblance to Sanofi’s Lantus, the world’s top-selling basal insulin. … Read more

Although three pilot programs came up short, experts say systems like PROMETHEUS could still succeed — if plan medical directors take an active role You can’t say the name isn’t ambitious. A system for bundling payments to various providers to allow them to share risk for an episode of care bears the moniker PROMETHEUS, and … Read more

United HealthCare is investing heavily in the Southeast’s managed care industry. The Minneapolis-based company intends to purchase HealthWise of America (not to be confused with Utah-based HealthWise, a Blue Cross and Blue Shield affiliate). HealthWise of America, based in Nashville, Tenn., operates HMOs with about 154,000 enrollees in Arkansas, Maryland, Kentucky and Tennessee, and plans … Read more

AVP-825 uses unique nasal anatomy qualities to avoid limits of additional intranasal delivery procedures. Areas covered: Materials keyphrases:’AVP-825′,”sumatriptan nasal powder’,”intranasal sumatriptan’,”sumatriptan safety’,”sumatriptan severe migraine’. Pharmacokinetic, Stage 2/3 reports, testimonials and also metanalyses/reviews were assessed. Expert opinion: AVP-825 stipulates an even more successful sumatriptan shipping system versus additional formulas. Pharmacokinetics revealed a single dose of AVP-825 … Read more

Medication manufacturers and also the companies which cover medication have been again squabbling in excess of why drugs are far really pricey. With got the capacity to up end the very profitable five-star relationship one of pharma businesses, carriers and pharmacy-benefit supervisors. Stocks of three really are all more vulnerable. That romance never been stress … Read more

The caveats: Recent research says the evidence for improved outcomes was of moderate quality. And VBID still hasn’t proved its mettle as a cost saver. It wasn’t a screaming headline, so it was easy to miss, but value-based insurance design recently turned a corner. Turns out it doesn’t just get people to take their pills; … Read more

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Every year, it seemed, I heard at least one speaker at some conference who lamented that managed care companies spent far less than their brothers in other industries, and that this was shortsighted. It sounded reasonable. After all, if “managing” is what a managed care organization does, if it doesn’t just pay the bills, the … Read more

University of Pennsylvania School of Medicine Full text in PDF ABSTRACT Purpose: To assess the relationship between patient cost-sharing (e.g., copayments or coinsurance) and adherence and persistence to second-generation (atypical) antipsychotic (SGA) medications. Design and methodology: A retrospective, observational study of adults aged 18-64 years with schizophrenia or bipolar disorder (n=7,910) who initiated SGA medications with employer-sponsored … Read more

These high-achievers wrestle with competing interests as they operate both in the medical and business worlds Frank Diamond Managing Editor After 13 years in neonatal intensive care, Marjorie Schulman, MD, became a clinician executive, working as a medical director. She left Aetna at the end of 2011. She loved it there, calling it an ethical … Read more

The executive director of the Foundation for Managed Care Pharmacy speaks of the challenge of reining in escalating drug costs. Michael J. Dillon has been in the front lines of the explosive growth of managed care and its effect on pharmacy over the last two decades. He began his career in 1979 as a staff … Read more

An HCIA-Sachs survey says the median HMO profit margin in 1998 was –1.7 percent, slightly better than in 1997. Forty-one percent of HMOs made money in 1998. Some marquee organizations are rebounding. Not-for-profit Kaiser Permanente ended 1999 with a net loss of $6 million, far from its $288 million net loss in 1998. On the … Read more

Regence says 40% of its total payments are already made through value-based care arrangements Regence, a Blues plan in the Northwest that has 2.6 million members, is launching a new bundled payments program in a partnership with Remedy, the Norwalk, Conn., company that specializes in software and support services for bundled payments. Regence says that … Read more

Treatment with erenumab Reduces the quantity of migraine in individuals for whom multiple traditional dental insomnia remedies have failed, in accordance with the consequences of a fresh phase III clinical trial released in The Lancet. The LIBERTY trial proves that therapy aimed against the calcitonin gene-related peptide receptor may offer a more well-tolerated and beneficial … Read more

A longitudinal study of 60,000 retirees enrolled in a large private health plan with an annual pharmacy coverage limit or a similar plan with no limit finds that after high-spending patients with $2,500 caps had exhausted their benefit, but before the end of the coverage year, their use of antidepressants, antihypertensives, antihyperlipidemics, and antidiabetic agents … Read more

At first glance, the ’98 HEDIS looks a lot like the ’97 model. But lift the hood and you’ll find that NCQA re-engineered HEDIS to give better performance, thanks to improved data-collection techniques. Michael D. Dalzell Senior Editor Sometimes, it’s what you don’t see that matters. Eight months from now, the 1998 Health Plan Employer … Read more

They play a key role in the new payment models. But coordinators aren’t coordinated, and patients are getting annoyed—and worse. Health policy wonks have been sounding the alarm for decades that the American health care system won’t get better until it is less fragmented and better coordinated. Vulnerable patients stay sick because the system is … Read more

The Health Care Financing Administration has given Maine officials clearance to offer a discount prescription program to 200,000 people without a pharmacy benefit. The program was developed after the pharmaceutical industry won a court injunction suspending Maine’s new law requiring the state to negotiate rebates and discounts for all uninsured residents. The latest program, modeled … Read more

By engaging patients and forming strategic alliances, plans can gain immediate cost and clinical benefits — despite conventional wisdom to the contrary. Trying to change the direction of the health care system is like steering a supertanker. It takes miles for a supertanker to make a small change in direction. And now the government says … Read more

Try ‘bundled payments, accountability, and consumer involvement,’ one surgeon advises Carol Milano New knees, hips, wrists, shoulders, and ankles are increasingly common in America’s aging, obese population. Every year, nearly 775,000 of us have a knee or hip replaced, reports the National Institute of Arthritis and Musculoskeletal Diseases. The American Association of Orthopedic Surgeons (AAOS) … Read more

In the aftermath with the 2007/2008 banking catastrophe, a significant assortment of reforms are introduced by European, domestic and international policy manufacturers being a response to problems by the banking industry which might have negatively influenced the whole sector. These efforts to cultivate sound and stable financial markets are completely encouraged with the insurance marketplace. … Read more

Why so high and why so #&*! complicated Are controversy and the threat of government intervention chilling drug-price increases or heating them up? As the start of 2018 approaches, Stephen Schondelmeyer, PharmD, PhD, takes the latter view. Reports that Congress or the Executive Branch may do something about drug prices don’t slow increases, says Schondelmeyer, … Read more

The ability of the computer to find unexpected — and often unwelcome — patterns of utilization is at the heart of today’s fraud detection methods John Carroll Contributing Editor The people who signed up for the yoga classes offered in the basement of one Philadelphia building didn’t know that the program included regular bills for … Read more

The Massachusetts secretary of state is waging war on the state’s not-for-profit HMOs, which financed the bulk of a campaign to defeat a ballot proposal that would have required the legislature to create a universal-care system in the state. William Galvin blasted the plans for poormouthing and cutting benefits while spending millions to defeat the … Read more

Real-World Evidence Might Take a Decade To Be Fully Established Jennifer Graff A Conversation with Jennifer Graff, National Pharmaceutical Council VP FDA, Gottlieb Get Real About Real-world Evidence RICHARD MARK KIRKNER Implementation of a new framework would secure RWE’s role in the drug-approval process. Walmart Came a-Calling. Emory Answered. LOLA BUTCHER Staying mad: Walmart gets … Read more

Have drug companies lost the incentive to develop products for small populations? What’s managed care’s stake? Over the past few months, lobbyists for the National Organization of Rare Disorders have joined hands with a bevy of patient advocacy groups to persuade members of Congress to amend a little noticed decision by Medicare to slice back … Read more

A brand new report finds that successful programs possess a third measurement outside financial incentives and superior dimension. You will find hundreds, or even tens of thousands of experiments occurring with healthcare. Much like CBD trainings, healthcare models are anyplace –together with countless promises regarding their efficacy. However, as using CBD, strict study has to … Read more

Fallout from the Medicare outlier-payment scandal is likely to force hospitals to try to replace that revenue. Health plans, prepare to negotiate! Ed Silverman Michael Cropp laughs in disbelief when he recalls the negotiating ploy tried by one hospital looking to obtain higher rates. “The hospital had just hired an excellent chief of cardiology, and … Read more

Some insurers and PBMs are experimenting with a pragmatic approach to covering testing Thomas Reinke Contributing Editor Pharmacotherapy biomarkers — those that predict drug response — and their related pharmacogenetic (PGx) tests are seen as the pathway to personalized medicine in cancer and other diseases, but their uptake has met resistance. Often they are supported … Read more

On average, CEOs for HMOs and other health care companies receive two thirds more compensation than their counterparts in other industries, according to the Crystal Report on Executive Compensation. In studying compensation packages for over 1,500 CEOs, Crystal found that the people at the top of HMOs and health care companies live better than CEOs … Read more

Despite Efforts to Decrease Health costs, CEO Reimbursement Continues to grow up 4 percent from 2013, the first time time cover has climbed from the previous seven decades, in line with the AP. The ACA is attempting to accomplish something positive about it. The legislation restricts Howmuch As stated by the Institute for Policy Studies, … Read more

Color charts Also available in PDF According to Health Risk Management Inc., a consulting company, states with higher quality of care generally have lower per-capita health care costs. HRM’s annual “Quality First” index includes 46 weighted quality indicators that consider what individuals, health care systems, and states do to affect health status and care, and … Read more

We’ve just had an interesting session at our State Medical Society Council on Ethics and Judicial Affairs. It dealt with peer review of medical expert testimony. Some members asked us to look into a perceived problem. Occasionally, a physician retained as an expert in a legal case offers an opinion or gives testimony that is … Read more

Obesity is common in heart failure and correlated with improved effects, frequently termed as the”obesity paradox”. Even though fat supply varies with gender, the use of obesity at the consequences of girls when compared to men using HF hasn’t yet been well-studied. At a cohort of higher level level HF patients followed by one faculty … Read more

Maybe, just maybe, accountable care organizations (ACOs) are the best bet for hitting the health care exacta of controlling costs and improving the quality of care. Figures released by CMS on September 16 showed that the 23 organizations in the elite Pioneer program and 220 in the Shared Savings program produced over $372 million in savings while … Read more

Michael D. Dalzell NEWS AND COMMENTARY The practice of caring for behavioral health patients in non-inpatient programs continues to grow, but a new study shows patients treated on that basis are getting dramatically less time with therapists.The 1997 annual survey of the National Association of Psychiatric Health Systems, which represents mental health and drug abuse … Read more

This surgeon and Harvard scholar says better systems emerge when those who encounter problems firsthand design the improvements themselves. Patrick Mullen This surgeon and Harvard scholar says better systems emerge when those who encounter problems firsthand design the improvements themselves. After 20 years as a practicing vascular surgeon, John Kenagy went through an experience as … Read more

The idea of a class-action lawsuit against HMOs was given a boost by a recent decision in a federal district court in Florida. Meanwhile, the Blue Cross and Blue Shield Association has sounded the alarm that efforts to increase health plan liability may be launched in at least eight states. In a Feb. 20 decision, … Read more

Costs are relatively low for this minimally invasive procedure, compared with open surgical interventions for vertebral compression fractures, such as internal fixation and spinal fusion. Susan A. Levine, D.V.M., Ph.D. Hayes Inc. Lawrence A. Perin, M.D., M.B.A. Chief of Medical Staff, Aviano Air Force Base, Italy Diane Hayes, Ph.D. Hayes Inc. and School of Medicine … Read more

Reformed UCR Calculations Not Without Problems Ingenix was criticized for understating UCR rates, but newer formulas also enrage members who get big balance bills   More than three years ago, health plans sat down with New York Attorney General Andrew Cuomo and his staff to hammer out a resolution to a thorny public controversy. Cuomo, … Read more

Vaccines for chickenpox and herpes, the two variations of the varicella-zoster virus, are now available for children and the elderly, respectively Recently the U.S. Centers for Disease Control & Prevention’s 15-member Advisory Committee on Immunization Practices (ACIP) voted unanimously to recommend vaccination of those 60 and older with a new vaccine — zoster vaccine live, … Read more

When Harris Health System began posting losses, it became apparent that a new compensation system, with incentives to providers to control costs, was in order. Risk sharing was the answer. As much as anything, managed care has meant change in the way physicians are paid. Capitation is becoming more widespread: Recent reports show 36-percent penetration … Read more

Mylan NL Leader Officer Heather Bresch can look at a Sept. 2 1 statutory hearing price increases because of the epi-pen emergency allergy therapy, ” the U.S. House of Representatives Oversight Committee said in an announcement on Wednesday. Mylan Was widely praised, for example by U.S. Democratic presidential candidate Hillary Clinton, for harshly raising the … Read more

Drug candidate shows clinical activity in phase II studies   The FDA’s Office of Orphan Products Development has granted orphan drug status to VAL-083 (DelMar Pharmaceuticals), a first-in-class small-molecule chemotherapeutic, for the treatment of women with ovarian cancer. VAL-083 previously received an orphan drug designation for glioma and medulloblastoma in the United States. In more … Read more

The hope is that sending a doctor, nurse practitioner, or pharmacist to a frail old person’s home will keep the patient out of the hospital John Carroll A new pilot program being kicked off at the Centers for Medicare & Medicaid Services may help make house calls a thing of the future for managed care … Read more

Some insurers are taking tentative steps toward developing global provider networks for corporate clients Until this year, the 27,000 people working for the Hannaford Bros. supermarket chain were on the hook for several thousand dollars in coinsurance if they needed a costly hip replacement. Yet the company was responsible for the lion’s share of the … Read more

The approval is based on data from the pivotal Phase 3’482 analysis, the greatest international multiple myeloma clinical trial conducted, that recorded 1,718 patients. “as much as 40 per cent of patients remain hospitalized to preventing bone complications, and also the percentage is highest among patients who have renal impairment during diagnosis,” explained Noopur Raje, … Read more

The chief medical officer for the Blues says plans should act now and work to affect future trends As chief medical officer and senior vice president for clinical affairs for the Blue Cross & Blue Shield Association, Allan M. Korn, MD, thinks a lot about how clinicians working for health plans can influence a patient’s … Read more

The majority City Health Works’ customers are inferior, juggling seven or even more prescriptions and confronting chronic ailments that often spiral unmanageable. Destini Belt-on is not a doctor or a nurse. She is an experienced wellness coach, also a trusted neighbor in Harlem, she moves where practices and hospitals cannot — to patients’ homes to … Read more

Key points Most of the current hospital performance measures do not identify the relationship between quality and cost of care and, therefore, are not health care efficiency measures. Current measures of physician efficiency do not identify the relationship between quality and cost of care. They should be considered cost-of-care measures, not health care efficiency measures. … Read more

Uncle Sam has decided to get behind the pay-for-performance effort in a big way, something some physician associations are less than thrilled about. About 140 standard measures of doctor performance in 34 clinical areas could be in place by the end of this year thanks to an agreement reached between the American Medical Association and … Read more

Affordable Care Act helps keep spending growth at modest level, report says Total health care spending growth is expected to average 5.8% annually over 2015–2025, according to a report published in Health Affairs and authored by the Centers for Medicare and Medicaid Services’ (CMS) Office of the Actuary (OACT). Projected national health spending growth remains lower than … Read more

John Halamka, M.D., among those highest-profile wellness IT leaders within the past decade, is exiting Beth Israel Deaconess Medical Center in Boston to get Mayo Clinic in Rochester, Minn.. A successful author and speaker, Halamka most recently been executive manager of Medical Technology Exploration Center to get Beth Israel Lahey Health at Massachusetts. He was … Read more

The aggregate remuneration for the most generously compensated clinic pioneers in Massachusetts rose 95% more than five years, with 12 of the heads detailing pay more than $2 million in the most as of late accessible year. In the latest year for which pay information are accessible, the 12 most elevated repaid medical clinic and … Read more

The ministry failed to state what the drug has been designed to be useful to get. A individual knowledgeable about the problem said the medication proved to be a cannabis-based pain-killer at the first phase of individual testing. The ministry said that the six volunteers at Rennes, in western France, have already been in good … Read more

That electricity morcellators should seldom be utilised in gynecological surgery due to the chance of spreading a concealed uterine cancer. The FDA stated the newest research are consistent with its 2014 quote that 1 in 350 girls who undergo a hysterectomy or fibroid removal is going to have concealed sarcoma. The danger of getting the … Read more

Endocrinologists say early treatment is essential, but health plans as a group are not yet on the same page In November, the Centers for Disease Control and Prevention reported an alarming statistic: Laboratory and claims data collected from health plans and state and federal databases such as Medicare showed that at least 1 in 4 … Read more

Are We on the Way to a Real ‘Learning Health Care System’? The fact that we waste hundreds of billions a year is all the more infuriating because we have the ability right now to stop the hemorrhaging Aiming at a Moving Target In Rheumatoid Arthritis As recommended treatment grows more aggressive, health plans should … Read more

As the costs of emergency surgery soar, new research published in JAMA Surgery has found that just seven procedures account for 80% of admissions, inpatient costs, complications, and deaths. In a separate commentary, Martin G. Paul, MD, of Johns Hopkins Medicine, wrote that the situation is a “looming catastrophe” as the annual cost of emergency procedures is … Read more

Give away healthy breakfasts and dinners to people with diabetes and it will help them control their disease. It’s no secret that central Pennsylvania’s coal country has been hurting since the industry went into decline. When the not-for-profit Geisinger Health did community health assessments, it learned that in some areas, economic woes were combined with … Read more

In Managed Care’s November 1999 issue, Al Lewis, president of the Disease Management Association of America, wrote about potential pitfalls facing DM. One identified by Lewis was state privacy laws, a topic that merits further attention. When the Health Insurance Portability and Accountability Act became law in 1996, it was the most sweeping health care … Read more

Officials across the country are watching to see whether the Sunshine State’s innovation can save money. John Carroll Contributing Editor PUBLIC AND PRIVATE When Florida picked a blue-ribbon task force three years ago to explore ways to fight rising health care costs, it didn’t take members long to zero in on disease management as a … Read more

FDA recommends turning away donors with infection risk As public health officials in the United States scurry to implement strategies to meet the Zika virus threat, one such tactic could exacerbate a different health concern: maintaining the nation’s supply of donated blood, according to Kaiser Health News. The FDA is encouraging blood banks—which already struggle to … Read more

BY JOHN LA PUMA, M.D. The Supreme Court decided last month that laws in New York and Washington states outlawing suicide were valid: Physician-assisted suicide is not a constitutional right. The fact that so many patients–almost two-thirds in most polls–consistently seem to want a suicide option is an opportunity for managed care to take the … Read more

Convenient care clinics, as they like to be called, are spreading quickly because members and plans like them Kathryn J. Alexander In the past 12 months retail clinics have spread like a rash over the health care landscape — the kind of rash they can easily treat in 15 minutes or less, for around half … Read more

Entire Worldwide spending oncology Drugs — for Example Curative treatments and supportive attention — reached the 100 billion threshold at 2014, whereas spending oncology medication at the U.S. climbed 5.3 per cent compounded annual growth pace in 2014 to reach 42.4 billion, based on another report. Total international spending oncology drugs — for example curative … Read more

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. A rural hospital may not know that it needs a telepharmacy service until a company makes a sales call and describes the innovation. The potential for better care and … Read more

To put the existing medication price disagreement into historical circumstance, we hunted the New York Times and Wall Street Journal in 1985 — 2015 and found concerns regarding medication prices have in common featured in the media over the analysis period with recently stricter forecasts for shift. Price grades, forms of inventions, stakeholder answers, and … Read more

Two sexual revolutions have happened within the previous 30 years: a massive increase in awareness of sexual problems and also the corresponding growth of providing therapy for sexual illnesses; and also a radical shift in sexual attitudes and sexual behaviour. Discussion centers around the ethical consequences of these adjustments. The standards of sex within this … Read more

THE CONTRARIANS Managed Care Was Founded by Contrarians You might not agree with them, but you can’t ignore them. The history of health care in the United States is filled with those who identified the system’s failings and offered new, unproven ideas. Is it time for a single-payer system? Are accountable care organizations unworkable? Will … Read more

Even though initial response prices are mild, the huge bulk of patients experience a relapse because to chemoresistance and succumb to their illness. What’s more, platinum-based chemotherapy is both noxious and also approximately 30 percent of mUC patients have been known for chemotherapy. Ergo, there’s a clear unmet need for publication, more efficacious therapy options … Read more

Nationalize it Re: “Reform — Does It Just Mean More Regulation,” October 2008. Milton Friedman said long ago, if health care is a right, it must be nationalized. It is a right. Ask any ER doctor. So a single-payer system will come. Thomas Allen Barley, MD North Vernon, Ind. Two sides of coin Re: “It’s … Read more

We Yanks might learn a thing or two about making decisive, countrywide health care decisions from our Canadian neighbors We in the United States are facing a crisis with the inequality and high cost of our health care services. We have a fragmented health care delivery system that functions with discrete silos of data. Creating … Read more

It’s no secret that health plan premiums are up sharply. Last year marked the first time since HMOs’ go-go period in the early- to mid-’90s that premium increases were higher than the increase in underlying medical costs. When medical costs slowed in the mid ’90s, premium hikes did, too — but the rates of increase … Read more

Everything is relative, but there’s been what many experts describe as substantial growth for a lot reasons Late last year, when analysts at Mercer looked at health plan adoption in the United States, they highlighted a key metric spotlighting the fast growth of the consumer-directed health plan (CDHP). Of all covered employees, 16 percent were … Read more

The FDA has Declared Supernus Pharmaceuticals’ supplemental new Medication Application asking a tag expansion for Trokendi XR to add constipation headache prophylaxis in adults and teens aged 12 decades and older, based on some media release. Supernus has been awarded provisional approval last summer with final approval determined by pediatric exclusivity of this medication at … Read more

The news that national health expenditures rose a modest 4.4 percent in 1996 is not likely to be repeated, according to a new estimate by Milliman & Robertson. Though M&R does not foresee an immediate return to the days of double-digit increases, its 1997 — 2000 health spending forecast predicts a moderate rise, due mostly … Read more

Filling the gap in coverage in which the enrollee pays 100 percent of total drug costs before catastrophic coverage begins — the so-called doughnut hole — will be a significant issue that stand-alone Prescription Drug Plans (PDPs) and Medicare Advantage Prescription Drug (MA-PD) plans face in 2008. In 2008, the coverage gap totals $3,216 for … Read more

Network instability is what happens when providers and health plans part company, or threaten to. Lately, many rifts have been the result of contract disputes, invariably conducted in public. Each side takes out full-page ads in newspapers and buys time on radio and TV to make its case to the public. Consumers get “dueling” letters … Read more

Neither providers nor health plans have had an incentive to manage post-acute care. That’s changing. Metrics and predictive analytics can help. For health plan leaders tasked with finding ways to manage the cost and quality of care delivered to their members, it is frustrating when patients with nearly identical diagnoses and levels of function follow … Read more

States will have a wide latitude in determining what constitutes an essential benefits package that insurers who wish to participate in exchanges will need to start offering in 2014. In a move that may make an uncertain situation even more uncertain, the Obama administration on December 16 issued guidance on what states can demand from … Read more

Medicine is a recession-proof occupation, which is good, since we don’t know how long the current downturn will last. And consider this: The Bureau of Labor Statistics says that from now to at least 2016, anyone with an MD after his or her name will be greatly in demand. “In addition to job openings from … Read more

POPULAR CONTENT TODAY’S POPULAR CONTENT Type Title Author Story A Conversation With Paul E. Terry, PhD: The Advantage of Progress-based Incentives webadmin Story Specialty drugs to spark next round of cost increases webadmin Story ‘Contact Capitation’ and its Cousins webadmin Blog entry Find and Fill: Gaps in Care Steven Peskin MD Story Wellness Programs: No … Read more

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 Complaints are coming. Given that the federal Centers for Medicare & Medicaid Services is cutting payments to Medicare Advantage (MA) plans — it started in 2011 and continues until 2017 — … Read more

At last, there’s a biosimilar-like competitor in the U.S. insulin market. Can Basaglar put some downward pressure on prices?   In December, Eli Lilly and Boehringer Ingelheim became proud parents, launching a new insulin product into the world. They dubbed it Basaglar, and it bore a striking resemblance to Sanofi’s Lantus, the world’s top-selling basal … Read more

Q&A A Conversation With Steve Miller, MD: Come in and Talk With Us, Pharma The man who has shaken up the pharmacy industry isn’t done yet. Interview by Peter Wehrwein You have been called a gatekeeper, judge and jury, cost-fighting ninja, and “among the most feared” by pharma. Which label is the most accurate? I … Read more

The fact that we waste hundreds of billions a year is all the more infuriating because we have the ability right now to stop the hemorrhaging Joseph Burns Contributing Editor Call it the $750 billion question. That’s the estimate for how much the U.S. health system wastes each year, according to the Institute of Medicine. … Read more

Peripheral Cardiovascular illness is just one of the very common indications of autoimmune disease globally. Peripheral arterial calcification reduces intense achievement and long‐term patency of endovascular treatment for PAD. Several calcium modification apparatus are offered for use within peripheral interventions. Thus we sought to execute a single patient‐level data pooled evaluation of studies that were … Read more

By David Volz Two groups of physicians in Florida have put a new twist on the old saying, “Beat them at their own game.” Frustrated with HMOs that are run by insurance executives, they’ve emulated medical societies in Connecticut and several other states by starting their own HMOs. These physician-owned plans, they insist, will be … Read more

Canadian researchers say there could be as many as 267,329 new cases of prostate cancer diagnosed each year by 2021. That would be 10 times as many as in 2009 (25,355 cases). Researchers in the department of radiation oncology at the Sunnybrook Health Sciences Center at the University of Toronto calculated prostate cancer cases using … Read more

The government wants to build an electronic system through which insurers, physicians, and hospitals can communicate. Snomed CT may solve a lot of problems. John Carroll Medical directors often complain that gathering health care data can be prohibitively expensive and severely hobbled by a conflicting set of competing electronic languages. But that may be about … Read more

Of all the “value-based” provider payment methodologies, this one’s the classic. And it may be mounting a comeback. The Macarena has yielded the dance floor, the TV hospital show E.R. is long gone, and the president is no longer named Clinton—for the moment, anyway. But the payment methodology that was white-hot in health care in … Read more

Drugs due to their anti-spasmodic, sympathomimetic, or parasympatholytic consequences in gastrointestinal disorder as well as other hereditary illnesses normally have important side effects upon the eye. Mydriasis and cycloplegia may raise the intraocular pressure and prevent severe attacks of cataract sometimes. However, this association of impacts is not inescapable, and also dicyclomine can be an … Read more

MICHAEL S. VICTOROFF, MD When I was young, I loved mythology. I read the Greeks and the Romans, and especially liked the Norse. Thor and Loki battling the giants — great stuff. It was a natural transition to science fiction and fantasy as a teenager. Go, Frodo! I’ve kept my interest in mythology and fantasy. … Read more

The FDA will make a final determination on regulations intended to permit the sale of ‘follow-on’ biologics Thomas Morrow, MD As insurers face the extreme costs associated with biologic agents, they wait for the FDA to create standards to ensure equal safety and efficacy for biosimilars. The discovery of the ability to modify the DNA … Read more

Name Last modified Size Description Parent Directory 28-Aug-2000 11:10 – ../../../../archiveMC/9711/QNA.1.GIF 17-May-2000 12:21 1k 9711.compmon.shtml 17-May-2000 12:19 1k 9711.outlook.shtml 17-May-2000 12:20 1k 9711.editorsmemo.shtml 17-May-2000 12:19 2k 9711.contents.shtml 17-May-2000 12:19 4k 9711.news.shtml 17-May-2000 12:20 7k 9711.legal.shtml 17-May-2000 12:20 7k 9711.washington.shtml 17-May-2000 12:21 8k 9711.employer.shtml 17-May-2000 12:19 8k 9711.ethics.shtml 17-May-2000 12:20 8k 9711.states.shtml 17-May-2000 12:21 8k ../../../../archiveMC/9711/9711.compmon.ext.gif … Read more

As waves of Physicians Proceed from Old methods of record keeping to New digital digital health record (EHR) systems, lots of caregivers say worries that implementing an EHR system inside their clinic may have dire benefits, for example more errors and greater patient mortality. However, Better engineering and financial incentives from the national authorities Promoting … Read more

The unfortunate distinction of being the state with the highest number of obese adults goes to Mississippi. According to a study by Trust for America’s Health and the Robert Wood Johnson Foundation, 35 percent of Mississippi’s adults are obese. “Obesity has contributed to a stunning rise in chronic disease rates and health care costs,” says … Read more

It’s one of the most thankless jobs in health care: denying a patient’s request for medical treatment. Before making such a decision, follow these steps to avoid bad-faith denials, warns an experienced medical director. A MEDICAL DIRECTOR’S VIEW HMO medical directors are caught in a Catch-22. We have to juggle the financial goals of our … Read more

Most health practitioners are rarely if convicted of prosecution. However, of people who’re, that there are a few serial offenders. As Reported by a newspaper Published Wednesday at the New England Journal of Medicine, only 1 per cent of American health practitioners could take charge for a whopping 32 per cent of legal asserts brought … Read more

FDA Expands Omalizumab Label for Allergic Asthma in Children Xolair now indicated for patients 6 to 11 years of age   The FDA has given the green light to omalizumab (Xolair, Genentech) for the treatment of moderate-to-severe persistent asthma in children 6 to 11 years of age who have had a positive skin test or in … Read more

Emergency care can be a emerging procedure requiring input from various health professionals within the clinic. To prevent crowding and economically flow patients throughout the ED, cooperation between professionals around multiple sub units is vital. Still, the multi disciplinary character of emergency maintenance presents a challenge into the optimisation of individual leak, as specialty and … Read more

“One size fits all” may be appropriate when tube socks go on sale, but when applied to health insurance financial incentives, it is almost always wrong, says A. Mark Fendrick, MD, director of the University of Michigan Center for Value-Based Insurance Design. He says this pervasive approach to plan design is hurting insurers as well … Read more

MANAGED CARE OUTLOOK U.S. asthma drug costs to jump 50% by 2023 Spending on medications to fight asthma will increase from $16 billion in 2013 to $23 billion in 2023 in the eight countries where most of these drugs are purchased, and one of the main drivers will be new products for severe asthma, according … Read more

Nowadays, every turn of a newspaper page, click of a media page on the Internet, or flip to a news channel brings us to an update, or more likely a criticism, of the public exchanges. With all of the attention on this side of the exchanges, we might be forgetting about the private exchange.   The private … Read more

Setting up external review process may be best defense against lawsuits Can insurance protect plans against punitive damages? Maybe. HMO did right by patient but lost the case anyway Third-Party Review: One Approach Puts HMOs In Harm’s Way External-review processes are all the rage. But what approach should be used: Developing a new medical opinion, … Read more

Combo treatment with lenalidomide and dexamethasone extends progression-free survival Positive results have been reported from an international, phase 3, randomized, double-blind, placebo-controlled study evaluating once-weekly ixazomib capsules (Ninlaro, Takeda Pharmaceutical Company) plus lenalidomide and dexamethasone compared with placebo plus lenalidomide and dexamethasone in patients with relapsed and/or refractory multiple myeloma. The findings were published in … Read more

Charges to patients receiving out-of-network care are exorbitant, according to a study by America’s Health Insurance Plans. “Health plans and their members routinely receive bills from physicians that are 10 to 20, or sometimes nearly 100 times higher than Medicare would allow,” says “Survey of Charges Billed by Out-of-Network Providers: A Hidden Threat to Affordability.” … Read more

A summary of ECRI Institute’s Emerging Technology Evidence Report Editor’s Note: Managed care leaders are striving to make evidence-based decisions about new and emerging health technology. Managed Care and ECRI Institute have collaborated to disseminate bimonthly summaries of the Institute’s Emerging Technology Evidence Reports. ECRI Institute is an independent not-for-profit organization that researches the best … Read more

Advancing technologies and new coverage designs are creating opportunities — and obligations — for health plan medical directors Walter S. Davis, MD, recently challenged an insurer’s decision about one of his patients. In a peer-to-peer discussion, the rehabilitation specialist spoke with a physician at the health plan about covering a new prosthetic device for a … Read more

Health plans could soon be required to develop systems to prevent drug interactions, as well as systems to monitor drug recalls and FDA alerts, under proposed accreditation standards issued recently by the National Committee for Quality Assurance. In the event of such problems, the health plans would then have to alert pharmacists, patients, and providers. … Read more

Just more than half of 489 large U.S. companies now offer their employees a consumer-directed health plan (CDHP), up from 47 percent in 2008, according to a new survey issued by Watson Wyatt and the National Business Group on Health. Another 8 percent are expected to adopt a CDHP by 2010. Companies with at least … Read more

Power to the People: Newt’s Battle Cry The former speaker of the house strongly favors a free-market overhaul of the system that would change the way consumers behave. Should you worry? Information: It’s Better When You Share Community health information networks failed in the 1990s. Today’s newer version — regional health information organizations — seeks … Read more

Guidances aimed to encourage innovative ways to the growth of digital health and fitness programs –for example innovative advice about clinical decision aid program. Department of Health and Human Services, also wishes to make sure its internal way of tackling these technologies advances alongside the maturation of digital wellbeing programs, as demonstrated by a statement … Read more

Sometimes images just stick with you like the tune that you can’t get out your head. After editing our cover story this month about insurance company mergers by Susan Ladika, the image I can’t get out of mind is a pair of sumo wrestlers going at it. Susan interviewed Tim Greaney, a professor at St. Louis University … Read more

Johns Hopkins physicians advocate for changes in how deaths are reported Johns Hopkins patient safety experts calculate that more than 250,000 U.S. deaths per year are due to medical errors. Their analysis, based on medical death rate data over an eight-year period, was published May 3 in the BMJ. The figure they reached surpasses the … Read more

ome health plans do a better job than others in bolstering physician satisfaction. Systems really matter. Frank Diamond It turns out that the National Committee for Quality Assurance, the Commonwealth Fund, Kaiser Family Foundation, America’s Health Insurance Plans, and the American Medical Association do not actually pinpoint particular health insurers that are the apples of … Read more

Omar Latif, Anthem Howard Wolinsky Roy Beveridge, Humana Howard Wolinsky Esteban López, Blue Cross and Blue Shield of Texas Howard Wolinsky Warachal Eileen Faison, Pfizer Scratching the Career Itch Leads To Bigger Reach in Pharma Timothy Kelley Eneida O. Roldan, Florida International University Climbing the Physician Leadership Ladder: The Top Rung Is Tough and Not … Read more

Formulary exclusions give them added clout with drug companies in this day and age of high-priced medications for conditions that really aren’t so rare. As PBMs honed their tactics to manage costs and therapy, formulary design evolved from a simple arrangement of a single tier to a complex arrangement with as many as five. Now, … Read more

Employers Move Into Primary Care As the number of onsite clinics at factories and office parks expands, will employers start to think they don’t need managed care contracts? Maureen Glabman Can a Medical ‘Facebook’ Help Your Plan Thrive? Doctors share cases, brainstorms, and gripes in today’s fast-growing electronic physician communities, and pharma companies want to … Read more

Back to the Future: The Re-Emergence of the Primary Care Physician A new model of care developed by the American Academy of Family Physicians places primary care physicians back at the center of care delivery UnitedHealth Stakes Claims On New Drug Safety Program One of the nation’s largest health care companies will analyze claims to … Read more

A Pennsylvania family physician saw a recent Managed Care article on communicating test results to patients and decided to share with readers some of the tools he uses for this important task. Here’s what he offers. Carl J. Forster, D.O. When I entered practice in 1976, I began with the philosophy that if a test … Read more

Even though That the U.S. Food and Drug Administration has declared the biosimilar replica of Enbrel, called Erelzi, including rheumatoid arthritis symptoms, gingivitis, ankylosing spondylitis as well as different diseases, Amgen is evaporating in U.S. national court its $4.7 billion annually medication contains patent coverage until 2029. Richard Francis, head of Novartis’s Sandoz generics firm, … Read more

The usual rulemaking process was circumvented by CMS, giving MA plans the OK to implement prior authorization and step therapy, says John Thompson, MD, of the American Society of Retina Specialists. Ophthalmologist John Thompson, MD, worries what would happen if a patient with age-related macular degeneration who’s had a stroke comes into his Baltimore office … Read more

Large insurers worry what will become of the hard work and money expended on the conversion if some providers get their way John Carroll When Dan Rode, the vice president for policy at the American Health Information Management Association, heard that the Department of Health and Human Services was proposing a one-year delay on the … Read more

Discrimination and Health Status Submitted by Steven Peskin MD on Sat, 2011-11-26 19:21 Diabetes discrimination heart disease Hypertension race Steven R. Peskin, MD, MBA, FACP Is Executive Vice President and Chief Medical Officer of MediMedia, USA, which publishes Managed Care Steven Peskin MD“You Can’t Outrun Your Past”…….. The title of a slide in a grand … Read more

Voters in Oregon are likely to be asked to decide in November whether to ban capitation in the state. Viewed as a test case for other states, the drive is being led by Gordon Miller, a Salem ophthalmologist. More than 73,000 signatures are needed to place the initiative on the ballot, and so far about … Read more

MEDICAL DEVICE MONITOR You Can Get There From Here With These New Mobility Aids State-of-the-art technology may soon make its presence felt in the home, battlefield, and even the pediatrician’s office Wichita State University researchers, under a $1.4 million U.S. Army Medical Research and Materiel Command grant, have developed a fast-setting splint that provides improved … Read more

LOOKING FORWARD For other articles in the series, see listing at end Al Lewis The young industry must clear some hurdles in the near future. Medicare stratification, disability management, and federal restrictions are worrisome. Then there’s that new law in California. To paraphrase the immortal words of Dan Quayle, there is an irreversible trend toward … Read more

Insurers should like contraceptives. They prevent expensive unintended pregnancies. But the rollout of ACA-mandated coverage has been bumpy. It’s been almost four years since the ACA’s contraceptive coverage requirements kicked in, and women have benefited from broader coverage and lower out-of-pocket costs for birth control. But that doesn’t mean this provision of health care reform … Read more

Every Year, the Country’s health system Spends countless dollars seeking to treathandle preventing a range of unfortunate ailments that just continue growing in prevalence. Chronic ailments. Patients who have chronic conditions account for 81 percent of hospital admissions, 91 percent of prescriptions filled and 76 percent of doctor visits. Roughly 86 percent of the $2.9 … Read more

Name Last modified Size Description Parent Directory 06-Jan-2001 16:01 – 0001/ 15-Mar-2000 21:06 – 0002/ 01-Jan-2001 14:05 – 0003/ 28-Apr-2000 09:13 – 0004/ 01-May-2000 23:41 – 0005/ 08-Jun-2000 12:01 – 0006/ 03-Jul-2000 22:10 – 0007/ 01-Aug-2000 18:24 – 0008/ 04-Sep-2000 22:03 – 0009/ 17-Nov-2000 10:25 – 0010/ 12-Nov-2000 00:36 – 0011/ 01-Jan-2001 12:52 – 0012/ … Read more

AHPs Aren’t required to Pay for All the Primary health benefits that ACA-compliant plans usually do, plus so they could base premiums in the own expected or paying for healthcare as opposed to putting premiums at the public speed. But critics say that you get everything you purchase. Association health programs operate like Traditional, important … Read more

Sign for Aczone® 7.5% Gel to comprise patients elderly 9 11. Aczone® 7.5% Gel is a prescription medicine applied to skin (topical) to treat inflammatory and also non inflammatory eczema, formerly approved in February 20-16 for patients 12 and older. “While acne Might Be commonly considered as a problem for teens, According to treatment plans, … Read more

Achieving Price Transparency Is in the Realm of the Possible John Marcille Uwe Reinhardt, PhD, in our Q&A, says — somewhat tongue in cheek — “… that is another miracle of American health care: We don’t know prices. We know Medicare prices — at least you could know them — because they are in the … Read more

A report issued by the Kaiser Family Foundation evaluates the level of insurance protection that consumer-directed health plans (CDHPs) provide women for maternity care. The study provides an estimate of maternity costs under three different clinical scenarios — an uncomplicated vaginal delivery, an uncomplicated Cesarean delivery, and a pregnancy with considerable complications — and compares … Read more

The Advisory Commission on Consumer Protection and Quality in the Health Care Industry is expected to recommend adding a few more letters to the health care alphabet soup. The new ingredients are a private agency to develop quality measures and a public entity to recommend quality goals. It’s unclear where creation of the private group … Read more

Health and Human Services (HHS) just released data on 2010 health expenditures, reporting that we, as a nation, have now reached the $2.6 trillion mark, consuming 17.9% of our GDP. Reaching that new mark required 3.9% annual growth vs. 3.8% in 2009. On the surface, the rate of growth seems less alarming than the insurance … Read more

Just who gets paid for what — and how much — is expected to change in a big way in 2010 John Carroll There are may pluses in the 2010 Medicare Physician Fee Schedule for primary care physicians — as well as health plans — to love. It’s the minuses directed at subspecialists that some … Read more

 Download PDF Abstract Purpose: The evaluation of obstructive coronary artery disease (CAD) is inefficient and costly. Previous studies of an age/sex/gene expression score (ASGES) in this diagnostic workup have shown a 96% negative predictive value, as well as an 85% decreased likelihood of cardiac referral among low-score outpatients at 45 days. The objective was to … Read more

September 11 underscored the prevalence of post-traumatic stress disorder. Screening could ultimately reduce utilization. But who should be screened? By coincidence, the anniversary of September 11 passed as Congress began debate on an updated mental health parity act. This juxtaposition, though, may help the bill’s chances of passage, considering that one lasting effect of the … Read more

CLINICAL PROTOCOLS It’s there on the Web, highly convenient. What keeps physicians away? Darcy Lewis Clinical practice guidelines — many of them competing and conflicting — have flooded medical practice along with the rise of evidence-based medicine. Before the late 1990s, if you wanted to study or compare guidelines for any medical condition, you had … Read more

Contracting with national laboratories saves money in the short run. But do health plans monitor quality well enough? Microbiologists worry. Contracting with large corporate laboratories to save money may be a winning health plan tactic in the cost-efficiency battle, but could be a losing strategy for quality and, ultimately, membership retention. To use Hollywood’s metaphor … Read more

Managing seniors with chronic conditions might get a little easier as the Centers for Medicare & Medicaid Services reports that the doughnut hole is shrinking, thanks to a deal reached by the Obama administration and pharmaceutical companies as part of the Affordable Care Act. Of course, this being an election year, the story will probably … Read more

What’s a doctor to do when her patients embrace the untried and outlandish — sometimes with their insurers’ blessings? Doreen R. Orion, M.D. When I recently moved my psychiatric practice to Boulder, Colo., I expected some major adjustments. Managed care was just taking hold here, and I knew I’d have to somehow find a niche … Read more

In nonconforming states, health plans will miss out on a bonanza of new members and hospitals might be on the hook for uncompensated  care While the Supreme Court’s majority opinion left the Affordable Care Act largely intact, it stripped away one provision that some of the most potent forces in the health care industry had … Read more

Latest Issue Table of Contents, March 2013 Download from App Store Read Digital Edition Download in PDF Resources Terms & Conditions for Using This Site Contact Us Disease Management Forum Call for Manuscripts Subscribe Address or Subscription Changes Rate Card and Production Requirements BPA Statement Classifieds Site Map Popular Content How Doctors Are Paid Now, … Read more

BY PHYLLIS MAGUIRE Symbolically, it’s great,” Paul J. Fink, M.D., former president of the American Psychiatric Association, says of the federal Mental Health Parity Act. “But in actuality, it’s nothing.” “It’s more than symbolism,” disputes E. Clarke Ross, D.P.A., executive director of the American Managed Behavioral Healthcare Association. “It required employers to re-examine mental health … Read more

Phase 3 Study Confirmed Drug’s Comparable Safety and Efficacy The FDA has approved etanercept-ykro (Eticovo™, Samsung Bioepis Co., Ltd.), a tumor necrosis factor (TNF) blocker and etanercept biosimilar, across all eligible indications for the treatment of rheumatoid arthritis, ankylosing spondylitis, plaque psoriasis, psoriatic arthritis, and polyarticular juvenile idiopathic arthritis. In a 52-week randomized, double-blind, parallel … Read more

Based on the current trend, with specialty drug costs growing annually by 20 percent, they will account for more than a quarter of all outpatient pharmacy expenditures by 2008. These findings were reported in CuraScript’s Specialty Pharmacy Management Guide and Trend Report, an annual guide highlighting the effects of specialty drug costs on employers’ health … Read more

Advocates say that what’s lost in lowered copayments is more than made up by lowered downstream costs, but skeptics find the data unpersuasive Richard Mark Kirkner Emerging evidence is showing that pharmacy benefits that use value-based insurance design (VBID) may encourage more people with chronic conditions such as diabetes or heart disease to take their … Read more

Health plans are among the major players in medicine that employers are turning to in an effort to combat rising costs associated with obesity. The Washington Business Group on Health in June launched a new effort, called the Institute on the Costs and Health Effects of Obesity, to address this troubling trend. The WBGH, a … Read more

Some question disease management’s cost-effectiveness, but major insurers have seen enough to induce them to expand programs We’ve grown accustomed in the last year and half to seeing seemingly invincible corporations and even entire industries suddenly find themselves wishing that the government would slap a “too big to fail” label on them. Most companies, however, … Read more

Full text in PDF Objectives: The objective of this study is to examine the acceptance of disease management programs (DMPs) for type 2 diabetes among patients as well as physicians in Germany. Background: DMPs began in the United States in the 1990s. The German government developed interest in DMPs for specific conditions and implemented them nationwide in … Read more

The CEO of StayWell Health Management discusses evolving approaches to health and wellness management under health care reform   The word “wellness” appears often in the Affordable Care Act. “It shows up 86 times,” says Paul E. Terry, PhD, CEO of StayWell Health Management, which works with employers to offer health assessments, health coaching services, … Read more

Factoring in the sociodemographics of patients might help improve them. But so would more transparency and openness by the hospitals.   Say what you will about the CMS hospital star ratings—and much has been said about them, mostly disparaging—their release accomplished something that’s a rarity in Washington these days: Republicans and Democrats in Congress came … Read more

TennCare is Your Nation Medicaid Application at the U.S. Country of All Tennessee. TennCare was created in 1994 under a national Waiver that approved deviations from the normal Medicaid rules. This had been the first nation Medicaid program to register Medicaid recipients in handled maintenance . [inch ] When first employed, in addition, it offered … Read more

The fifth installment of the Annual Business Practice feature Includes a perceived Wages inequity: Your Own coworker Robert is He made an informal mention to his wages, as well as your dismay, it’s 20 per cent higher than yours. He is fine, however so much as you are aware, his career path has less or … Read more

Employed as a certified professional adviser has its own downs and ups, specially once you face problems very similar to those of one’s clientele. I have endured social stress for a massive portion of my own life. I remember days at middle school and higher school once I stressed myself sick, remained home, neglected to … Read more

Seniors oppose cutting the Medicare Advantage (MA) program to fund the Medicare physician payment fix, and believe cuts to MA will hurt them, according to a study jointly conducted by Ayers, McHenry & Associates and the Feldman Group on behalf of America’s Health Insurance Plans. This opposition was voiced by enrollees in traditional Medicare and … Read more

Better-informed patients need not be a bane to other players in the health care industry. Interaction doesn’t have to be adversarial and should include the historical “have-nots.” Four themes will continue to grow in importance as the shift to consumer and patient empowerment continues into the 21st century. Consumers will want more and better information so … Read more

The typical life expectancy of hospitalized patients with IPF is just 3 to 4 decades. Reduction in forced vital capacity in patients with IPF is apparently nearly linear, together with patients using well preserved FVC at baseline undergoing exactly the exact same speed of reduction in FVC as patients with more complex illness. 2 antifibrotic treatments … Read more

UnitedHealthcare’s Bold Effort to Deal with Cancer Drug Costs Oncologists may no longer mark up the cost of specialty drugs. If the plan works, you can bet that other insurers will adopt something similar. Joseph Burns A Conversation with Allan M. Korn, MD: It’s Time to Get Aggressive On Patient Safety The chief medical officer … Read more

When we truly begin to manage the person and not the condition, there will be payoffs on both the cost and quality fronts Emad Rizk, MD Managing the care of members with chronic disease — especially those with multiple conditions — is one of health care’s most confounding and costly challenges. As an industry, we … Read more

The lack of a consistent clinical strategy for treating weight gain means coverage for obesity isn’t imminent. Public policy must be established first. From a public health standpoint, there is no question about the importance of the fact that 61 percent of Americans are overweight or obese. But developing a consensus on public policy — … Read more

A summary of ECRI Institute’s Health Technology Forecast Report Editor’s Note: Managed care leaders are striving to make evidence-based decisions about new and emerging health technology. MANAGED CARE and ECRI Institute have joined in a collaboration to bring bi-monthly summaries of either an ECRI Institute Emerging Technology Evidence Report or a Health Technology Forecast profile. ECRI … Read more

Total direct Reimbursement for High Medical Insurance Providers Compensation climbed between 8 percent and 14% from 20-19 to 20 20. It is greater than the 3% growth in annual revenue for all these organizations throughout the exact identical period. This was one of the main findings of BDO’s Health-insurance Executive Insights Report. The analysis discovered … Read more

Over the past four years, HMOs have shown signs of solvency, stability, and strength, a turnaround from the financial crisis of the late ’90s. With mergers and consolidations leading the way, there were fewer — and better run — companies, with improved underwriting discipline. A look at annual impairment (a euphemism for failure) counts reveals … Read more

For the first time, HEDIS data will be included. Health plans will have to focus on results as well as systems to pass muster. The National Committee for Quality Assurance didn’t have to reach far to grab what it considers a useful tool to improve its evaluation of health plans. Its new accreditation process uses … Read more

This article also available in PDF Abstract: Results for disease management [DM] programs have not been as positive as hoped because of clinical issues, lack of access to capital, and administrative issues. The financial experience of DM programs can be quite volatile. Financial projections that are protocol-based, rather than experience-based, may understate the revenue required and … Read more

Von Willebrand disease (VWD) is distinguished with its own heterogeneous clinical symptom, which disrupts its identification and control. The clinical direction of VWD has stayed essentially unchanged within the previous 30 decades approximately, with von Willebrand factor (VWF) targets, desmopressin and anti-fibrinolytic representatives as chief tools to regulate bleeding. That is compared to hemophilia A, … Read more

Doctors continued to operate round the clock at 20-16, However they Additionally started to turn off specialization lines made to function certain markets of all patients. Those services Aren’t just more suitable for individuals, however they also By way of instance, it’s far more affordable to use a microhospital compared to the usual significant teaching … Read more

72015 was a good year for those looking for hopeful answers to quality questions and who want the momentum to carry into next year. Consumer Reports teamed up with the University of California–San Francisco (UCSF) and the California Department of Insurance to create California Healthcare Compare, a quality and price transparency tool. Consumers’ Checkbook unveiled … Read more

In an evolving market, insurers want to see what members’ relationships with retail health clinics will look like A decade ago, when Blue Cross & Blue Shield of Minnesota made a bulk purchase of visits to the health clinics that were opening in Target stores and pharmacy chains — and then passed them on to … Read more

Women who are enrolled in Medicare HMOs and who are diagnosed with breast cancer are more likely to be diagnosed at an earlier stage than women covered by fee-for-service Medicare, according to research in the Journal of the American Medical Association. A National Cancer Institute/Health Care Financing Administration study of 22,000 women with breast cancer … Read more

Also available in PDF United HealthCare surprised many in 1999 when it announced that it was doing away with utilization management. Just what the health plan subsequently did, and how it did it, has been a subject of debate. There’s little doubt, however, that precertification had helped to make HMOs a convenient villain in society. … Read more

Follow this link to PDF version A new study contends that the “feeding frenzy” of recruiters banging down the doors of young primary care physicians is over, thanks partly to consumer demand for direct access to specialists. Merritt, Hawkins, & Associates has been surveying young PCPs in their final year of training since 1991. The … Read more

NEWS AND COMMENTARY Are investors bullish on managed care again? HMO stocks made a stunning comeback in the first quarter of the year. The holding companies of four of the nation’s 10 largest for-profit HMOs have recently traded near two-year highs, bouncing back from 1997 sell-offs. Winners: United HealthCare, Sierra Health Services, Humana and United … Read more

The number of obese and overweight people in nine developed countries will increase alarmingly by 2022 and, unfortunately, the United States will lead the way, according to a study by the consulting company GlobalData. High caloric intake mixed with an increasingly sedentary lifestyle means that the United States will have about 113 million obese and … Read more

Compensation for medical directors and CMOs at staff-model health plans and in high-deductible health plans, as well as HMOs and PPOs, remains competitive when compared to what their counterparts at hospitals, physician practice groups, and in about 15 other categories get paid, according to Cejka Search. For all physician executives in general, the average compensation … Read more

Chronic Illness New Battleground For Retail Clinics, Primary Care Physicians Doctors have pretty much made their peace with retail clinics for problems like sinusitis and routine vaccination. But they aren’t ready to concede care for chronic conditions to the retailers. Just when it seemed that retail clinics and primary care practices were learning to live … Read more

Paramedics Providing Palliative Care in Home has been The intention of this analysis was to judge patient/family pride and paramedic relaxation and optimism. In Part A, we accumulated viewpoints of patients/families via polls sent at enrolment and telephone interviews after a meeting. Replies were reported descriptively and from thematic investigation. In Section Bwe surveyed paramedics … Read more

As we were putting this issue of Managed Care to bed late last month, the U.S. Supreme Court issued an opinion with important implications for our readers. In upholding states’ authority to impose third-party review of HMO coverage denials, the high court sought to resolve conflicting decisions by two appellate courts about the legality of … Read more

Health plans are increasingly involved in promoting the lifestyle changes that help their members avoid cancer, and are increasingly involved in clinical trials if prevention fails Contributing Editor See also accompanying story: Plans Put Greater Emphasis On Cancer Management This year about 1.45 million people will be told they have cancer. Most will begin an intense, … Read more

The FDA wants to significantly shorten the development time for new medications by cutting years out of the R&D process The FDA has several regulatory avenues mapped out for the most promising new drugs in the pipeline. A favored therapy can be put on the agency’s fast track, offered an abbreviated priority review, and occasionally … Read more

CMS’s data-liberation movement is helping to accelerate the transition to value- and risk-based payment systems. For payers and providers, the trick is knowing what to do with the data. Over the past two decades, a lot of low-hanging fruit has been lopped off health care costs. Inpatient days per thousand have come down by about … Read more

In prostate cancer. But, atezolizumab in conjunction with paclitaxel protein-bound–an alternative combination therapy–is now approved for treating adult patients using mTNBC whose tumors state PDL1, as determined through an appropriate test. Continued endorsement of atezolizumab in conjunction with paclitaxel protein-bound can depend on demonstrated advantage of this treatment from additional trials. Healthcare professionals must not … Read more

Nosedives in the stock prices of such health companies as Oxford Health Plans, Aetna U.S. Healthcare and MedPartners have focused attention on the question: Does poor performance on Wall Street affect quality of medical care? While an answer to that question realistically cannot be known for years, falling health care stocks apparently have spooked the … Read more

  John La Puma, M.D. Viagra is on every man’s lips, but not as much as we’d like. Managed care organizations have started to limit access. According to the Associated Press, Aetna offers no coverage. Kaiser Permanente is studying it. Prudential and United HealthCare cover some patients, depending on the plan. Cigna will pay for … Read more

CMS has broadened the services that Medicare Advantage plans can provide—services that may reduce expensive treatments and injuries. Insurers continue to see the market as a business opportunity. Critics see a slow-motion privatization of Medicare. The feds have a bullish 2019 forecast for Medicare Advantage (MA), which puts private health plans in charge of managing … Read more

From dodgy data to uncooperative doctors, difficulties confront health plans that are trying to stratify providers by cost and quality John Carroll Contributing Editor By her own account, Dolores Mitchell has tried most of the usual tactics in the managed care playbook for reining in health insurance premiums. Tiering pharmaceutical products has led to a … Read more

BY JOHN A. MARCILLE There’s a charming little children’s book called Pierre, written by Maurice Sendak in 1962. In the story, pint-sized Pierre could say nothing but “I don’t care” whenever his parents spoke to him. When a hungry lion threatened to eat Pierre, the crumb crusher’s comeback was “I don’t care.” Pierre became the lion’s … Read more

FDA Ponders How To Regulate Next-Generation Sequencing In light of the tremendous implications for overuse, misunderstanding, and abuse of a person’s genetic and disease-risk data, regulators have a lot to think about The FDA is weighing the appropriate regulatory approach to next-generation sequencing (NGS), in which a single test potentially can be employed to identify … Read more

Engaging Busy Physicians Key to Improving Outcomes Barry Patel, PharmD For centuries, the problem in medicine was too little information. Now there’s too much, and doctors need help coping. The amount of research published in health care is astounding. Thousands of studies are disseminated each year on research ranging from personalized genetic-based drug therapies to … Read more

Vivitrol is only medication labeled for relapse prevention In a multicenter, randomized clinical trial, former prisoners who received six monthly injections of extended-release naltrexone (Vivitrol, Alkermes, Inc.)––a medication that blocks opioid receptors in the brain––were significantly less likely to resume opioid use than were those who received counseling and referrals to community treatment centers without … Read more

The to Try out Act, or Even the Trickett Wendler,” Frank Mongiello, Jordan McLinn, also Matthew Bellina Directly to Try out Actwas signed into legislation May 30, 2018. This regulation is just another solution for those who’ve now already been diagnosed using lethal ailments or states who’ve attempted all accredited remedy plans and who’re not … Read more

Isn’t this what your mother told you? Go to medical school, specialize, and make a lot of money. Managed care dented her wisdom, but didn’t sweep it away; in fact, the loosening of traditional managed care restrictions in recent years has come largely at the expense of primary care disciplines. The renewed demand for some … Read more

Advance directives are among the most studied topics in medical ethics. They are a logical approach to an intimate subject. Nearly everyone recommends them, but relatively few patients — a maximum of 25 percent, and probably fewer — have them. Advance directives are controversial, and probably will become more so. There is keen interest in … Read more

Even as the health insurance industry comes under increasing political fire (Medicare for All, anyone?), it continues to lure beneficiaries into Medicare Advantage, with 2019 looking to be the best year ever for the program. Of course, as has been noted, MA plans may have an unfair advantage over traditional Medicare. MA plans bid against … Read more

PRACTICE IMPROVEMENT In 2000, Gregg Omura, MD, saw 20 patients per day. Today, he sees about 30 patients daily, takes home substantially greater pay, and has more satisfied patients, along with a happier staff. “I also feel that I’m not working as hard,” adds Omura, whose family practice is part of Primary Care Partners, a … Read more

The Bush administration is plowing toward a goal long sought by health plans and long-resisted by physicians: putting every patient’s health history on electronic medical records. First, President Bush touted the idea in a speech to the American Association of Community Colleges on April 26. “…Within 10 years, every American must have a personal electronic … Read more

NYLCare Health Plans of the Mid-Atlantic has paid the state of Maryland a $40,000 fine for limiting patients with chronic illnesses to 30-day supplies of medication. A 1997 state law allows patients access to 90-day supplies. NYLCare is revising its policies to allow members to obtain 90-day supplies at pharmacies and by mail.

Brilinta’s price will be a significant factor in coverage decisions when Plavix goes off patent in May 2012 Thomas Morrow, MD About every 20 seconds an American is admitted to the hospital for acute coronary syndrome. ACS is not a single disease but a spectrum of disorders defined by their various clinical presentations. Although the … Read more

Health Plans: Important Considerations for Medicare Part D Bids Editor’s note: The Managed Care website is read by people in many areas of health care, and by the public too. This article will be of most interest to our readers in health plans. Medicare plans are furiously working to develop an optimal 2015 bid to submit … Read more

A new era of health care is in store for our nations veterans with the passage of the Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Outside Networks (MISSION) Act, the most comprehensive health care reform bill passed by Congress since the Affordable Care Act. The MISSION Act provides the largest access to care expansion … Read more

Benefits of Aveo Pharmaceuticals are decreasing after the organization announced in a national filing that it was terminating its Stage II analysis of ficlatuzumab, an HGF inhibitory antibody, together with cancer drug Tarceva being an Firstline treatment method for EGFR-mutated non-small cell lung cancer patients. At the 8-K filing registered Sept. 9, Aveo explained that … Read more

Two out of three Americans say they would be “extremely,” “very”, or “somewhat interested” in having health savings accounts (HSAs), which were launched January 1 as part of Medicare reform, according to a new survey. Destiny Health Plan, a 30,000-member insurer in Illinois, surveyed 1,008 adults between January 22 and 25. Only 12 percent of … Read more

Color charts Also available as PDF Most physician and lay managers in group practices saw modest compensation increases from 1997 to 1998. Medical directors, however, proved the exception, as their median compensation level fell 14 percent. A breakout of the data indicates that the more time spent on administrative duties, and the greater the share … Read more

Some physicians are putting new emphasis on careful, active listening to patients. Organizations that don’t encourage this may be ignoring a tool for controlling costs, retaining enrollment and improving medical care. Listen to the patient: He is telling you the diagnosis,” Sir William Osler counseled his fellow physicians at the dawn of the 20th century. … Read more

Financially, did health plans do better last year than in 1998 — or worse? The answer may depend on whom you talk with and the indicators you consider. The rating company A.M. Best says for the first nine months of 1999, profitability of 9 of the 15 largest publicly traded MCOs improved over the same … Read more

Portrait

In tying copayments closely to the actual cost of medications, Humana takes a step toward promoting awareness of resource use. Steve Perlstein Humana faces many of the same challenges as other managed care companies when it comes to prescription drugs. All pharmaceuticals — generic and brand alike — are getting more expensive, and those cost … Read more

Collaboration is the name of the game these days, but even when lower-level providers speak up, will physicians really listen? So many innovative efforts in care delivery double back to the decades-old problem of physician buy-in. That’s true even as the Affordable Care Act moves from law to reality, or some version of reality (talk … Read more

Spending on ambulatory care has increased recently, with more than half of it going to physician offices, according to Census Bureau data (http://tinyurl.com/Census-amb). Spending on ambulatory services rose 23.5% from 2007 to 2012. Physician offices earned about $405 billion from ambulatory care in 2012, up 20.6% from the approximately $336 billion earned in 2007. Not … Read more

Scientific studies sometimes produce surprising conclusions, and one published last month in the New England Journal of Medicine, indicating that for-profit health plans involved in Medicare+Choice provide just as much access to high-cost medical procedures as not-for-profit competitors, certainly did. The lead author himself was caught off-guard. “We actually didn’t believe it when we first … Read more

The insurer hopes to give businesses of between 50 and 400 employees more flexibility under defined contribution Frank Diamond Officials at Horizon Blue Cross Blue Shield of New Jersey think that they might have found a niche customer base. The public health insurance exchanges opening in October will include the Small Business Health Options Program … Read more

Primary-care practices are hurting, with bankruptcies by the week, but California’s problems today won’t necessarily be everyone else’s tomorrow. California’s trademark model for care delivery, the large multispecialty practice, is known as an entity but understood by few. Save for pockets where capitation has taken hold (Pacific Northwest, Texas), this model is foreign, even to … Read more

The trickle-down approach to coverage—worry about employers and consumer satisfaction takes care of itself—doesn’t work in the new health care environment. CXOs gain traction. Joseph Burns Contributing Editor Tweet Widget(link is external) Poor customer service is out. We’ve known that for many years. Now in health care, even mediocre customer service is out. CMS said … Read more

Each year the National Committee for Quality Assurance releases its huge report on what’s going on in the health care industry: The State of Health Care Quality. It’s professionally presented and packaged, and always chock full of the sort of information that can keep those who toil in managed care, as well as those who … Read more

Tanquilut wrote,”While traders have seen PillPack for being a risk factor for retail shops… [that the ] litigation proves that PBMs now are additionally in danger to be disintermediated, specially if efforts to contract with big donors profits grip.” And, even though a PillPack representative wouldn’t comment to the socket, PillPack CEO TJ Parker said … Read more

Name Last modified Size Description Parent Directory – 0006.compmon.html 16-Jul-2007 08:25 5.3K 0006.contents.html 13-Jul-2007 12:20 3.6K ../../archives/0006/0006.cover.jpg 01-Jun-2000 12:00 9.0K 0006.editorsmemo.html 16-Jul-2007 08:25 2.7K 0006.ethics.html 16-Jul-2007 08:25 7.1K 0006.groups.html 16-Jul-2007 08:25 14K 0006.homehealth.char..> 10-Dec-2002 09:44 8.0K 0006.homehealth.html 16-Jul-2007 08:25 15K 0006.incentives.html 16-Jul-2007 08:25 25K 0006.legal.html 16-Jul-2007 08:25 7.3K ../../archives/0006/0006.news.chart.gif 01-Jun-2000 12:00 9.0K 0006.news_big.html 16-Jul-2007 08:25 … Read more

Medical Practioners eagerly Searched the advanced-education charge they can get by attending the occasion. From the program statement, Pfizer also enable the doctors know traveling expenses, hotel and food are subsidized — with a total of 762 (roughly $840) each person. The info Pfizer delivered the Berlin Medical Association to declare that the application unabashedly … Read more

Health reimbursement arrangements (HRAs) have fewer rules, but health savings accounts (HSAs) create more of an incentive to shop for health care. The increasing popularity of account-based health plans poses a problem for anyone in the position of having to explain what they are and how they differ. The two main versions, the health savings … Read more

No bloody firefights or government closings were expected as members of Congress got to work on fiscal year 1998 funding bills after their August recess. Most of the issues, in fact, had been settled by the House andSenate appropriations committees during the summer, but were tabled by a flareup over prohibiting abortions under Medicaid managed … Read more

MANAGED CARE June 2003. ©MediMedia USA The argument that disease management could save the system money in the long run has often been met by the retort that HMOs do not have a real incentive to back such programs because of the way enrollees jump from plan to plan. Health Plan A’s wonderful DM efforts might wind … Read more

The Department of Health and Human Services has lifted its moratorium on enrolling new home health agencies in the Medicare program. President Clinton instituted the moratorium in September 1997 after government studies uncovered a pattern of fraud and abuse in the Medicare home health industry. But in the last four months, the department has introduced … Read more

Q&A: National Data, National Impact We need to reduce unwarranted geographical variations in care Elliott Fisher’s e-mail box is full these days, the result of communications with congressional staffers working on health care reform. Fisher and his team at the Dartmouth Atlas Project are intent on making sure the bills going through Congress help create … Read more

The Department of Labor has issued new guidelines concerning the wellness provisions of the Affordable Care Act (ACA) that relate to the use of financial incentives, and the Office of Health Plan Standards and Compliance Assistance is seeking public comment. This document proposes “amendments to regulations, consistent with the Affordable Care Act, regarding nondiscriminatory wellness programs in … Read more

Purpose: To evaluate the cost-effectiveness of telemedicine services in patients diagnosed with preterm labor (PTL). Design: Women hospitalized with a diagnosis of PTL during a 3-year study period were identified within a health maintenance organization. Inclusion criteria: singleton gestation, stabilized after tocolysis and discharged from the hospital, and participation in the HMO’s preterm- birth prevention … Read more

Cost pressures that plans associate with rising drug expenditures result partly from their own largesse. Solutions: Restore consumerism and forge a common agenda with drug companies. BY MICHAEL D. DALZELL Senior Editor   Sidebar: A new legal pitfall in DTC advertising Jim Hoyes is under no illusions. As vice president for managed care at Sanofi-Synthelabo … Read more

It seemed a good idea to sell the practice to a hospital, but it didn’t work out. When a doctor wants or has to leave, there are things to negotiate. Caught in the riptide of change, hospitals in many regions have ventured into the private practice of medicine in the past 10 years in an … Read more

Patient advocacy groups work overtime to kill legislation that businesses felt would have provided less costly coverage for their employees John Carroll In the end, some of the most influential public support for opposition to a Senate bill backing low-cost association health insurance was drummed up by a red push-up bra. In a demonstration of … Read more

“NASDAQ hosts a number of earth’s most advanced biotechnology and healthcare businesses and is just a natural match for Organovo,” said Keith Murphy, CEO,” Organovo. “We feel this movement will continue to work into the longterm advantage of our customers.” Organovo layouts also creates usable, threedimensional tissues for use in clinical therapeutic and research uses. … Read more

“The Concept of Owning small Companies Jointly Buy health Insurance has intuitive appeal, and it’s been encouraged by thoughtful wellbeing economists and analysts using widely different philosophical outlook. The experiments with the concept have demonstrated less powerful than anticipated.” This opening announcement by Dr. Eliot Wicks at 2000 catches much Of this 15+ year policy … Read more

It’s No Longer Just Members Who Are Suing Health Plans Providers that once feared insurers’ retribution are finding strength in numbers and compensation in class action litigation Maureen Glabman Health Plans Join Up For the Genomics Revolution Some of the biggest insurers in the country scramble to make sense of a field that will change … Read more

Can disease management vendors really show a strong return on a health plan’s investment, or are the data just too malleable to be useful? As the chief medical officer for Maryland-based Coventry Health Care, Bernard Mansheim, M.D., has had plenty of opportunity to look into the disease management companies that routinely drop by to peddle … Read more

The German Consortium for heritable breast/ovarian cancer plans for nationally usage of practitioner, individualized nonetheless ordered maintenance for families in high risk. Our analysis assesses counselees’ faculties, referral techniques, expectations and motives regarding their own very first genetic consultation. All Counselees could engage through a survey. Enriched Networking comprehension of hereditary cancer motivates patients, for … Read more

CARE MANAGEMENT: THE NEXT WAVE OF MANAGING CARE? The executive director of Kaiser’s Care Management Institute says guidelines have a place in every HMO, but there’s more to care than that. Medical roots run deep in the man who is leading the transformation of medical care delivery at the nation’s largest HMO. Both of Peter … Read more

Physician demand may finally be on the horizon. The only question is whether the personal digital assistant, smart phone, or another variety will dominate. Joyce Ochs, MBA It appears that physicians are joining other professionals who find the ubiquitous PDA (personal digital assistant) to be indispensable. Data from Manhattan Research, a health care and life … Read more

A U.S. General Accounting Office report says 11 percent of state licensure actions against physicians that were reported to the National Practitioner Data Bank had inaccurate or misleading information…. Payments made to physicians jumped 5.2 percent in 1999, while accounting for 32 percent of health care cost increases that year. A study by the Center … Read more

Venetoclax for the treatment of patients who have chronic lymphocytic leukemia that possess a chromosomal abnormality named 17p deletion and that were treated using one or more prior therapy. Venclexta is your first naturopathic treatment which targets that the bcell lymphoma two proteinthat promotes cancer cell development and can be overexpressed in several patients with … Read more

Now the U.S. Food and Drug Administration declared the Mini-Med 770G System, a hybrid loop diabetes control apparatus that’s designed to mechanically track sugar and supply appropriate basal insulin concentrations using very little if any input by the users or their practitioners to be used by individuals aged two to 6 weeks with type 1 … Read more

Does the Stark II law ever permit you to contract for designated health services that may be technically prohibited, but do not trigger improper behavior or create dangerous financial inducements? For example, suppose a hospital wished to offer financial incentives to physicians to keep the doctors in the community. Such incentives are usually not permitted … Read more

After 25 years, the Healthcare Effectiveness Data and Information Set (HEDIS) is still criticized for focusing on process and taking up doctors’ time. But it has been incorporated into physicians’ workflow and may yet be instrumental in bringing about value-based care. In 1991, the average premium for a family with employer-sponsored health care was less … Read more

By Ed Silverman Picture a drug that has been compounded for decades and sold at a low price. The FDA approves a new formulation, and the price goes through the roof. MANAGED CARE May 2011. ©MediMedia USA Picture a drug that has been compounded for decades and sold at a low price. The FDA approves … Read more

Overall enrollment remains highest in preferred provider organizations (PPOs), with 3 in 5 covered workers enrolled in this type of plan, according to the Employer Health Benefits 2009 Annual Survey issued by the Kaiser Family Foundation. HMO enrollment continues to be relatively higher (31 percent) in the West and significantly lower in the Midwest (10 … Read more

They are part of PPACA’s effort to cover as many people as possible. Insurers will be forced to remake their businesses. The Patient Protection and Affordable Care Act (PPACA) is designed to expand health insurance coverage to people who fall into the cracks — people who are jobless or self-employed, who can’t buy insurance because … Read more

For decades, managed care plans have sought to stop paying fees for services. Now they’re trying bundled payments for episodes of care. Arkansas is on the leading edge of a movement to limit fee-for-service payment. Its weapon of choice is a modified version of bundled payment for episodes of care. Critics say bundled payment is … Read more

Methotrexate remains a first-line choice of treatment for patients with rheumatoid arthritis (RA), with an average of 72 percent of patients receiving the agent as first-line therapy. Rheumatologists believe it is the best first-line therapy — it’s cost effective, and evidence of its efficacy is supported by three decades of clinical study. Among biologic treatments … Read more

Imagine a land of physician entrepreneurs. They own their offices, decide which hours they’ll work and choose their patients. And, yes, get paid pretty well. They’ve never worked for a third party, never had to offer a discount, and never had to justify or explain anything to anybody except maybe to their own consciences. They’re … Read more

With rising health care costs and higher health insurance deductibles, hospitals could find themselves in trouble with patient bad debt if they don’t make improvements in collecting out-of-pocket payments, according to an article in HealthData Management. The Boston-based Aite Group predicted that patient payments to hospitals will increase at a compound annual growth rate of … Read more

Georgia Democratic Sen. Nadine Thomas has been trying to push managed care reform issues — such as giving patients the right to sue their HMOs — through the state legislature for years. But business and HMO industry influences have too often killed these bills, says Thomas, a registered nurse. This year was different. As the … Read more

Health plans see value in rewarding physicians for participating in their specialty boards’ maintenance-of-certification programs A board-certified cardiologist or internist or pediatrician used to be like the Pope: The physician passed a test just once, early on, and carried the “board-certified” designation for life, no requalification or retesting required. Board-certified physicians who are held to … Read more

For many affected by vitreous degradation, surgery was the only treatment until the development of ocriplasmin Unless you have been involved in ophthalmology specifically, you have probably never heard of a sight-threatening condition called vitreomacular adhesion (VMA). There is limited epidemiologic data about this progressive, commonly asymptomatic disease, and the precise incidence has not been … Read more

Managed care is doing its job. It has markedly reduced overtreatment and employer expenses for health care. It has forced efficiency where there was little, and pushed physicians to communicate better with each other and with their patients. Managed care has also caused a lot of angst. Physicians and patients alike are angry about the … Read more

At a glance “Communicating Health Care Quality: How Pioneering Employers Keep Consumers Informed” Published by Employers Managed Health Care Association, Washington, D.C. This 32-page report looks at how several large employers are measuring the quality of care delivered by managed care plans, and how the companies are getting that information into the hands of employees … Read more

Efforts are under way to find out exactly how pharmacy benefit managers work their magic In health care, pharmacy benefit management companies are the Wizards of Oz, the folks behind the curtain. As drug prices skyrocket, the companies promise health plans, employers, and the federal government magical savings, and they often deliver. Studies show PBMs … Read more

Can HMOs be sued for the practice of offering bonuses to physicians who help them keep the cost of care down? That’s a question the U.S. Supreme Court has agreed to decide this term, in the first major case involving HMO liability to reach the high court.involving HMO liability to reach the high court. An … Read more

Plans are increasingly trusted with management of the ABDs — aged, blind, and disabled This summer California will mark the beginning of a new era for the Medicaid managed care business. After winning a waiver from the federal government last fall, the state’s aged, blind, and disabled beneficiaries — the ABDs, in the parlance of … Read more

Mark D. Abruzzo, J.D. On June 12, the United States Supreme Court, in unanimous fashion, held that treatment and eligibility decisions by physicians under contract with an HMO are not fiduciary decisions under the Employee Retirement Income Security Act. More specifically, the court stated that the breach of fiduciary duty claims predicated on the existence … Read more

Despite popular usage, these two terms mean different things, especially when coverage decisions need to be made There is a genuine difference between effectiveness and efficacy, even though the words are often used interchangeably. Effectiveness describes how medication is used in a real-world setting where patient populations and other variables cannot be controlled. Efficacy describes … Read more

Thanks to recent Supreme Court rulings, manufacturers of generic drugs are in a good position to continue expansion of their market share Laws are evolving in favor of the generics industry as the demand for generics grows. Several recent Supreme Court decisions in particular are having a significant effect on the industry — decisions that … Read more

There is very little competition in the biopharmaceutical sector. With the introduction of generic forms of human growth hormone, can managed care get a lower price? The holy grail of managing the explosion of the biologic drugs may well be signaled by the the availability of generic biologics. The FDA does not have a process … Read more

Price and physician reluctance to swap it into complicated regimens for heart failure could explain tepid sales. Novartis’s Entresto came to market in 2015 in a blaze of glory. A combination of valsartan, an angiotensin receptor blocker, and sacubitril, a neprilysin inhibitor, Entresto’s rise to stardom started when its pivotal phase 3 study, the PARADIGM–HF … Read more

On Jan. 4, 2001, HCFA issued a final rule governing the Stark federal antireferral law. Actually, HCFA issued a final rule — Part 1. HCFA intends to finalize Stark in two phases. Part 2 will be issued sometime after the 90-day comment period for Part 1 lapses — perhaps as long as a year to … Read more

Name Last modified Size Description Parent Directory 01-Mar-2005 11:31 – ../../../archives/0004/acpe.logo.line.GIF 01-Apr-2000 12:00 1k 0004.news_fallout.html 09-Apr-2003 23:31 1k 0004.news_cigna.html 09-Apr-2003 23:31 2k 0004.news_whatdrugs…> 09-Apr-2003 23:31 2k 0004.news_liabilityc..> 09-Apr-2003 23:31 2k 0004.news_humana.html 09-Apr-2003 23:31 2k 0004.news_amap.html 09-Apr-2003 23:31 2k 0004.news_reportcard..> 09-Apr-2003 23:31 2k 0004.news_headlines…> 09-Apr-2003 23:31 2k 0004.compmon.html 09-Apr-2003 23:31 2k 0004.news_financial…> 09-Apr-2003 23:31 2k ../../../archives/0004/bms.logo.gif … Read more

PUBLIC RELATIONS Doctors who use the news media to criticize others, rather than initiate a constructive dialog about difficult issues, help erode the profession’s influence. Tim Olsen Criticizing your customers and your colleagues is a sound business practice that will help you position your industry in the best possible light. Sound like a wise public … Read more

The five principal aims of the 1979 Surgeon General’s report were to improve the wellness of the U.S. populace in five big life span stages. Different points of interest were targeted at each age category, such as low birth- weight and birth defects such as babies, and functional freedom, flu, and pneumonia such as elderly … Read more

Is it ever OK to withhold information — or even to lie? Last month’s report in Health Affairs generated headlines for at least a week. “Survey Shows That at Least Some Physicians Are Not Always Open or Honest With Patients” contained some eye-opening statistics that should definitely be taken seriously. One third of the 1,800 … Read more

Health plan executives as well as physicians can benefit from reading what this consultant has to say about the managed care contract clauses doctors should cross out and initial — or regard as “deal-killers.”   Perhaps the most prevalent of “deal-killer” provisions today is the “hold-harmless” clause. The hold-harmless clause essentially says that the physician … Read more

Color chart    also available in PDF The American Medical Association’s annual physician income survey shows that, on average, doctors are making close to $200,000 a year. Random interviews with 4,000 physicians revealed a mean income in 1996 of $199,000 after expenses and before taxes–about a 2-percent increase from 1995, and almost 10 percent higher than … Read more

A CONVERSATION WITH TOM MILLER Tom Miller, the director of health policy studies at the Cato Institute, says choice matters more than antiquated systems. Tom Miller is director of health policy studies at the Cato Institute, a conservative, nonpartisan public policy research foundation founded in 1977 and based in Washington, D.C. The institute is named … Read more

BY JOHN A. MARCILLE Managed Care has two main groups of readers: practicing physicians and health care plan executives. As you might imagine, crafting stories that will be of interest and use to both groups is quite a challenge. Every month we reject proposals that are one-sided, inflammatory, self-serving and/or short-sighted. But don’t for a … Read more

The cost of Cuprimine (250-mg oral capsule), a drug used for rheumatoid arthritis and Wilson’s disease, increased 2,143%, from $6 in 2011 to $135 in 2015. In that same time period, the cost of Stelara (a solution of 45 mg per half millimeter), a drug used to treat autoimmune disorders, rose 93%, from $5,523 to … Read more

Express Scripts’ program manages biologics dispensed under the pharmacy and the medical benefit Market forces and the implementation of parts of the Affordable Care Act force insurers to adjust their strategies constantly, but they’re not the only health care stakeholders doing so. A recent effort by Express Scripts, the giant PBM, illustrates how quickly the … Read more

Merck Published results out of The Stage III KEYNOTE-604 trial of its own Check Point inhibitor Keytruda using chemotherapy at extensive-stage smaller cell lung cancer. The research met one among its double primary end points, progression-free survival, but overlooked one other end point, complete survival. “consequences of KEYNOTE-604 revealed the possibility of Keytruda, in conjunction … Read more

Physicians are fairly ignorant of what consumer-directed health care will mean to them in terms of relations with patients and health plans Melodie Blacklidge, MD, first heard the phrase in 1999. A savvy executive from Procter & Gamble called to ask the Cincinnati pediatrician if she could take her six-year-old in for a strep test. … Read more

Women age 65 and older are the biggest users of antidepressants, but use is up across all categories, according to a report by Medco called America’s State of Mind. The PBM reviewed prescription drug claims for more than 2 million people to gauge the use of mental health medications between 2001 and 2010. Men, women, … Read more

The FDA has approved four continuous glucose monitors. The days of painful fingerpricks to measure blood sugar levels with glucometers finally may be over for many patients with diabetes, especially for the 1.2 million Americans with type 1 diabetes but also for at least 1.75 million patients with type 2 diabetes who control their condition … Read more

PET, CT, MRI — these and other imaging technologies are valuable but costly. Aetna, Cigna, and a few other plans lead in clamping down on unnecessary use. Sara P., 60, who works for the Miami school district, traveled to South America last summer for a facelift that cost less than half of what she would … Read more

Psoriasis Patients’ Options Include Effective Oral and Injectible Drugs There are two basic delivery choices for psoriasis medications, says Kenneth Gordon, Professor of Dermatology at Northwestern University. While biologic therapies given as shots have higher response rates, new oral medications such as apremilast and tofacitinib work well, cost less, and may appeal to patients who … Read more

Many labor organizations have been isolated from inflationary realities. Can health plans and employers make them see the light? As General Electric and its unionized workers continue to negotiate new contracts, health care will be the No. 1 issue on the agenda — and workers aren’t going to give in easily to premium and copay … Read more

Years ago, my staff and I pored over handwritten notes and unsigned prescriptions in order to address patients with chronic diseases. For the first time, we were using data to determine patients’ needs and deploying our clinical resources to meet those needs—before the patients suffered complications or sought care themselves. For most physicians today, this … Read more

Wal-Mart laws aside, many factors converge to steer legislatures away from being too intrusive Back in 2003, when the number crunchers at PricewaterhouseCoopers did the math on health premiums, they fingered dozens of new state insurance mandates as contributing to a painful 13.7 percent spike in premiums. This year, when PwC went back to its … Read more

Better management of patients with ulcerative colitis and Crohn’s disease could possibly lead to cost savings and certainly better outcomes, according to a study in Gastroenterology. Intestinal resection surgery for these inflammatory bowel diseases ensured a much better survival rate than surgery given in emergency departments (EDs), according to researchers at the University of Calgary. The … Read more

Health insurers are getting behind a bill that would ditch a federal requirement that annual increases in Medicare+ Choice payments fall below spending increases for fee-for-service beneficiaries. Rep. Mike Bilirakis, a Florida Republican, introduced the bill as plans stampeded out of Medicare. HMOs with 300,000 members said they will quit Medicare next year because of … Read more

If clinical mistakes were as common as clerical ones, nobody would leave a hospital alive. Something needs to be done, and done soon. Michael S. Victoroff, MD The U.S. medical claims payment system was designed by Kafka and implemented by Monty Python. Its inefficiency and high error rate are exacerbated by a disappointing volume of … Read more

Is your practice ready to succeed under managed care? Answering that question with a practice assessment need not be a time-consuming ordeal. Here’s how to do the job if you only have half an hour. Greg N. Korneluk You already know the benefits of practicing preventive medicine. By applying those principles of prevention to the … Read more

The family is poor, unable to afford housing anywhere except the Navajo Nation, more than 300 miles away from the Phoenix Children’s Hospital. Family members—including a very sick child—are insured by UnitedHealthcare Community Plan–Arizona (UHCCP), a managed care Medicaid plan. In one year, the insurer spent nearly $300,000 on services for the family, including emergency … Read more

Unable to find an acceptable suitor for HIP Health Plan of New Jersey, state officials on March 31 closed the deeply indebted HMO they seized late last year and are liquidating its assets. Regulators ordered other HMOs in the state to accept HIP’s 144,000 commercial subscribers without regard to existing medical conditions. Last month, a … Read more

MANAGED CARE April 1997. ©1997 Stezzi Communications At a glance California Consumer Health Scope www.healthscope.org Developer: Pacific Business Group on Health, San Francisco, regional employer health coalition Goal: Provide comparative data on health plans and hospitals, as well as general health care information, to consumers Strategy: Establish World Wide Web site, use employee newsletters to build awareness of site To … Read more

Return to Jackson Hole? The Push for a Standard Benefit A nationwide discussion about making health care available to all Americans gives new life to an old idea Finding Opportunity Where Business Models Meet The next stage of payer-provider collaboration will add true value Although Employers Need Depression Programs, They May Not Know It Yet … Read more

The Bush administration is moving to loosen health-privacy protections by requiring that providers tell patients about their privacy rights and make only a “good-faith effort” to get a written acknowledgement of that notice. The new regulations, which became official on Aug. 14, are expected to take effect April 2003. The insurance industry, which lobbied hard … Read more

Washington Initiatives Speaking of potential computer fiascoes posed by the dreaded Year 2000 bug, Republican Rep. Bill Thomas of California and Health Care Financing Administration boss Nancy-Ann DeParle are continuing their battle over its potential effects on Medicare beneficiaries. Thomas’s take: “Mismanagement is undoing the [Balanced Budget Act] and taking money out of the pockets … Read more

DTC is recognized in roughly 60,000 people in America each Year, and radioactive iodine is suggested for all those who have known/suspected metastases in diagnosis and also those at elevated risk of recurrence. 2 a tiny percentage of patients usually do not reap the benefits of currently offered treatment together with RAI only because they … Read more

Employers believe in this hybrid approach. Is it time for medical insurers to look at it carefully? Combining state-of-the-art mainstream medicine with a range of less-traditional but evidence-based therapies is becoming an accepted, cost-effective option for improving patients’ health. The blended approach is referred to as integrative medicine. Increasingly, integrative techniques that have been validated … Read more

MANAGED CARE November 1999. ©1999 MediMedia USA Mark D. Abruzzo, J.D. The development of peer review is linked to the development of hospitals and the increasing responsibility assigned to hospitals for the quality of care rendered by physicians on the hospital medical staff. Its roots have expanded with the onset of managed care. Peer review now is … Read more

Delaware Gov. Thomas Carper last month signed a bill that puts coverage of mental illnesses on much the same footing as physical illnesses. Health insurers must use the same terms and conditions in covering biologically based mental illnesses that they use to cover physical illnesses. While employers in other states have tended to oppose mental-health … Read more

How it will fit into the universe of cancer drug development and regulation are just many of the questions that come to the fore. The use of real-world evidence (RWE) by clinicians and drug manufacturers is rapidly unfolding in oncology. RWE has the potential to provide oncologists with fresh insights into treatment decisions, given the … Read more

Nearly 2,000 patients died over five-year period Hospitals and doctors’ offices nationwide might have avoided $1.7 billion in malpractice costs––and nearly 2,000 patient deaths––if medical staff and patients communicated better, according to an article posted on the STAT website. A report from CRICO Strategies, a research and analysis offshoot of the company that insures Harvard-affiliated … Read more

By reducing restenosis, these devices will save managed care money. Technophiles would be hard pressed to come up with better names than Cypher, Cypher Stallion, Achieve, Taxus, Express and Maverick. But it is unlikely that most managed care executives would guess that these names represent an industry that, up until now, has been neglected by … Read more

The health care industry should take into account outcomes when weighing the cost of new treatments and technologies and make quality-adjusted life years (QALYs) part of the equation, say the authors of a study in the April issue of Health Affairs. One needs only to look at how medications revolutionized the treatment of HIV in the … Read more

Hospitals lose “Opportunities Abound in Reform’s Wake” in the May 2010 edition fails to address that the reform is going to help insurance companies who never help hospitals. Hospitals will be closing. Director of Pharmacy Services New England Sinai Hospital Stoughton, Mass. In patients’ hands Thank you! “Put DM in Doctors’ Hands,” in the March … Read more

Bioethical issues in women’s health mostly revolve around reproduction. Who, why, when, where, and how people reproduce have been sources of discussion and sharp disagreement for a few thousand years. Birth occupies a seat — next to death — in the front row of the great bioethics study hall. Most ethical questions arise from someone’s … Read more

CONTRIBUTING VOICES Lawmakers Take Interest in Hep C Drug Pricing Neil Minkoff, MD Multiple news outlets are reporting that a letter signed by Representatives Henry Waxman, Frank Pallone Jr., and Diana DeGette was sent last week to the CEO of Gilead asking for justification for the high price set on its new Hepatitis C medication, … Read more

Briefing document precedes advisory meeting   According to an FDA briefing document, the level of accuracy of the G5 mobile continuous glucose monitoring (CGM) system (Dexcom) is “close to, but not as good as, typical self-monitoring blood glucose meters in the U.S. market.” The briefing document was released July 19, two days before a scheduled … Read more

For every 10 percent increase in the use of generic, rather than brand-name, statins, Medicare costs could be reduced by about $1 billion annually. These would be direct Part D savings achieved via the price difference between the brand and generic, according to John F. Hoadley, PhD, a health policy analyst at the Georgetown University … Read more

When new pharmaceutical products enter the market, the lack of real-world experience with these drugs creates quandaries for payers and providers alike. Often, all there is to go on is the minimum required for FDA approval—non-inferiority to a comparator product in terms of efficacy and safety. If an existing medicine is less expensive than the … Read more

Need for Desire Drugs Debated Some see a big market for medications for low libido in women. But sales of Addyi have been slow. Has a normal experience been unnecessarily medicalized? Jan Greene For ED, the Doctor Is in But the Men Are Staying Away Physicians find men lack interest in seeking medical care if … Read more

GPs at the Uk Remain Prescribing antibiotics to get a massive percentage of patients that struggle sore throat, otitis media, upper respiratory system infections, and chamomile despite federal guidance warning against that particular, based on a study published this week predicated on analysis of this world’s biggest primary care database. The Study analyzed antibiotic treatment … Read more

Assay detects misfolded amyloid-beta peptides in early disease Researchers in Germany have developed a blood test that may allow the detection of Alzheimer’s disease (AD) at an early stage. The test consists of an immunochemical analysis using an infrared sensor. The sensor’s surface is coated with antibodies that extract biomarkers for AD from blood or … Read more

The analysis included individuals with MS and optic disease, which can be Damage to the nerve which transmits information from the eye into the brain. Optic nerve damage can be a frequent effect of the illness. “This research is exciting because It’s the first to show “this is done with a medication which has been … Read more

In Five Key Clinical Areas — What Falls Through The Cracks When Quality Is Measured? The idea of evidence-based medicine lies at the heart of managed care. But looking only at today’s fairly crude quality indices would be like measuring a diamond with a tape measure. Does pressure for ever-improving quality ‘scores’ endanger the real … Read more

Health plans and physicians have every right to hold down the cost of pharmaceuticals, as long as patients aren’t harmed. But not everyone agrees on what actions are acceptable. Richard R. Abood, R.Ph., J.D. MANAGED CARE August 1997. ©1997 Stezzi Communications Health plans and physicians have every right to hold down the cost of pharmaceuticals, as long … Read more

Worldwide, there’s dissatisfaction with all current, input-oriented along with supply-led healthcare systems. These procedures are inundated by monodisciplinary and coordinated maintenance and effect in fragmented care procedures, suboptimal quality and waste of funds. There’s consensus that faulty provider payment techniques donate for the issue. Specifically, overriding payment techniques create significant incentives for healthcare providers about … Read more

If you haven’t already heard about the negative impact of formulary restrictions on adherence, well here it is. With mixed messages regarding formulary restrictions’ impact on patients, a recently published systematic literature review, published by Happe, et al., sought to get to the bottom this. It analyzed 93 studies published in 1993 or later and … Read more

Although it was stable in the mid-1990s, the proportion of physicians without any managed care contracts rose from 9.2 percent in 2000–2001 to 11.5 percent in 2004–2005, according to a report by the Center for Studying Health System Change. “This small, but significant, increase could signal a trend toward greater out-of-pocket costs for patients and … Read more

A survey of 12,000 top-level benefit and human resource managers, owners, and CEOs of small to mid-size businesses conducted by Kaiser Permanente reports that if the financial hardship of providing health care coverage were to be rated on a medical pain scale from 1 to 10, with 10 being extreme pain, the average would be … Read more

The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) made numerous recommendations for first-line therapy for patients with high blood pressure. While JNC-7 places an emphasis on diuretics, it acknowledges the roles of several classes of hypertension drugs, including beta blockers, calcium channel blockers, ACE … Read more

In a marketplace fraught with downsizing and restructuring, many top administrators find themselves having to change careers. Vignettes: Abbie Leibowitz, MD Kevin Roache, MD John C. Beeson, MD, MBA When Anthem purchased HMO of Colorado and HMO of Nevada as part of a larger deal, George Kandel, MD — the plan’s longtime CEO and medical … Read more

There is no denying that Wal-Mart has become the fashionable whipping boy of American industry. Whether that’s fair or not is debatable. The company has trouble insuring part-time workers, something that most big companies have difficulty doing. To its credit, the company is launching a counteroffensive that includes a marketing campaign — as well as … Read more

The Academy of Managed Care Pharmacy is testing a plan to have drugmakers submit evidence-based outcomes analyses when seeking formulary inclusion. Jack McCain Contributing Editor FORMULARY DEVELOPMENT Drug formularies ideally are meant to protect health plans against exorbitant drug costs, and to provide members with an array of safe and appropriate products with demonstrated cost-effectiveness. … Read more

Don’t dismiss this development in Web communication. Blogs — the best of them — conduct serious and extensive discussions of health care policy and provide important new information. Blogs have been around for almost a decade now, yet many professionals in health care have failed to recognize their value. Judicious reading of some of them … Read more

The Affordable Care Act stunts the growth of these institutions, but will quality of care and competition suffer as a result? The Affordable Care Act prohibits construction of new doctor-owned hospitals if those institutions want to accept Medicare or Medicaid patients, because government officials worry that the doctors’ financial interests in such institutions encourages more … Read more

I read with great anticipation the Viewpoint in the June 2019 issue of Managed Care titled “U.S. Infant and Maternal Mortality Rates: Shamefully (and Unnecessarily) Bad and Getting Worse.” The author, François de Brantes, offered three suggestions: make participation mandatory for seven states that chose not to participate in perinatal quality collaboratives (PQCs); institute innovative … Read more

With Medicare for all emerging as a defining issue in the 2020 election, single payer health care seems more plausible than ever. But for Medicare for all to truly work for all Americans it must do more than provide uniform, basic insurance. It must also create room for consumer-driven choice. In more than 60 consumer … Read more

The National Committee for Quality Assurance has been tapped to help the Centers for Medicare and Medicaid Services (formerly HCFA) monitor plans that participate in Medicare+Choice. NCQA has been granted so-called “deeming authority” for the M+C program. Margaret O’Kane, NCQA president, says that this means that plans can satisfy many of their M+C requirements during … Read more

As expensive products increase their share of the medication market, expect these methods to be employed widely Ira Studin, PhD, MPH Escalating specialty pharmacy (SP) costs, together with a mixed picture on long term effectiveness and problems of adherence, will make it necessary for insurers to rely more heavily on traditional managed care methods to … Read more

High daily copayments for high-priced hospitals are coming into fashion. It’s all about shifting costs, but what about quality of care? John Carroll Contributing Editor The art of tiering health benefits — which got started when health plans began linking prescription drugs to an escalating schedule of copayments — is taking a giant leap into … Read more

New physician specialists like laborists, surgicalists, and nocturnists are beginning to fill specific niches in the provider market. While the data on their compensation are still somewhat limited, their presence should be noted, according to the 2007 Physician Compensation and Productivity Survey Report issued by Sullivan, Cotter & Associates. Laborists treat only women in labor … Read more

Free-market advocates question state say-so over major hospital projects. They have a strange bedfellow.   Richard Mark Kirkner Is health care a free market? Legislators in Florida and Virginia want it to be, so they are moving to scrap the laws that require health care providers to get state approval before they expand or add … Read more

The number came as a surprise even to Montana State University Professor of Nursing Peter Buerhaus, and he’s been writing about medical workforce issues for years: The supply of rural physicians—their numbers few in many sparsely populated areas—is projected to fall 23% over the next decade. That finding came in a study co-authored by Buerhaus—its … Read more

If you’re the kind of person who knows — and perhaps takes pride in having achieved — all the right numbers (e.g., blood pressure, LDL-cholesterol, HDL-cholesterol, triglycerides, C-reactive protein, body mass index), you probably should stop reading right now. Because otherwise you might choke on your tofu. (Which is a very healthful food, and you … Read more

Initial bids are in and it appears that premium growth will be slowing even more in 2007, according to a report by Hewitt Associates. On average, HMOs are proposing to raise premiums 11.7 percent next year. The companies last year initially asked for 12.4 percent increases. Some experts think that the rate increases might wind … Read more

HIV Disease is responsible for You of the most Catastrophic Person pandemics. The arrival of antiretroviral therapy has altered the class of this outbreak and saved tens of thousands of lives. Complex therapeutic regimens are introduced since 1996 and also have led to the transformation of HIV illness to some curable chronic ailments. Yet the … Read more

Discrimination persists in many areas, but slow progress is being made Perhaps never before have so many organizations done so much in such a short time to improve health care for the lesbian, gay, bisexual, and transgender (LGBT) community. While significant strides have been made, much more must be done, say advocates for that community. … Read more

Paul Terry Having just finished reading Walter Isaacson’s brilliant rendition of Steve Jobs’s life and career, I’ve considered whether there are health care marketplace lessons to be garnered from his central casting in the extraordinary tech wars for primacy over the past 25 years. I’d commend this biography to anyone who loves great writing and insightful analysis … Read more

Providers that once feared insurers’ retribution are finding strength in numbers and compensation in class action litigation Maureen Glabman Contributing Editor Health insurers are under siege, and it’s not from stockholders upset over cratering equity prices. Lawsuits are coming at the plans from places they haven’t come before at a rate they have never seen … Read more

Pharma will fight it, but Donald Trump and Bernie Sanders both see liberalization of the rules for drug importation as a way to bring prices down.   For presidential candidates, advocating for more drug imports as a way of driving down consumer drug costs can make for a neat campaign sound bite while taking a … Read more

No news is good news for managed care plans that often have been battered in the press, but it isn’t the only kind of good news. A recent poll by Harris Interactive shows that the public’s perception of health insurers is improving. (The poll of 1,010 was conducted by phone April 5-10.) “Managed care companies … Read more

Together with Declining levels of estrogen in postmenopausal women, bone intake is significantly more than formation, that induces a bone negative balance. Ergo, these women are especially prone to osteoporosis. In China, post menopausal osteoporosis is getting to be a critical public health issue as a result of the rapid gain in the normal expected … Read more

MANAGED CARE December 2010. ©MediMedia USA Adding pharmacists to the primary care team right in doctors’ offices might help patients with chronic diseases manage their risks better, a new University of Alberta study suggests. The blood pressure of patients with type 2 diabetes dropped significantly when pharmacists were included in the on-site clinical examination and … Read more

Last July, the Office of the Inspector General of the Department of Health and Human Services issued a ruling that many gainsharing programs between hospitals and physicians were illegal. Hospitals and physician groups were outraged, and they vowed not to take it. Now they’re trying to do something about it. And it all involves just … Read more

charts Increased national attention to women’s health care issues during the 1990s has produced mixed results. According to a Commonwealth Fund study, the percentage of women who receive mammograms and who take calcium supplements to prevent osteoporosis has increased, but there has been no noticeable increase in other types of preventive care. Worse, it says, … Read more

Less is More On April 4, the American Board of Internal Medicine Foundation launched Choosing Wisely, a campaign to educate health care professionals and consumers about tests or procedures that should be questioned because of lack of evidence that they’re needed and/or because of evidence that says the tests or procedures should not be done … Read more

NEWS AND COMMENTARY Plans Help Bridge Cost Discussion Put yourself in the oncologist’s position: Would you want to discuss with a patient the cost of the cancer care he is receiving? Reaction to a new study suggests that health plans can make this patient-physician conversation less awkward. The study by Tufts Medical Center suggests that … Read more

Color charts Gaps in Medicare coverage can mean significant out-of-pocket expense for low-income elderly and disabled recipients. Many such Medicare recipients are eligible for Medicaid assistance for Part B premiums and services not covered by Medicare, such as prescription drug coverage. But a report by the Kaiser Commission on the Future of Medicaid suggests that … Read more

With 11th-hour negotiations over the fate of Tennessee’s once ambitious health program for the working poor and Medicaid population — TennCare — running right up to Managed Care’s deadline, it was impossible to tell just what might emerge from the talks. Gov. Phil Bredesen and patient advocates have been wrangling over either rationing care for … Read more

Low-income seniors will have fewer Part D prescription drug plans to choose from in 2009, according to an analysis conducted by Avalere Health. Avalere found that 1.3 million low-income Medicare beneficiaries will be automatically reassigned by the end of 2008. Six states — Arizona, Florida, Hawaii, Maine, Nevada, and New Hampshire — will each have … Read more

Medicare Advantage is healthy despite concern about reductions in federal payments as a result of health reform. The program will grow by 10 percent this year, according to the Kaiser Family Foundation. “The Medicare Advantage marketplace is robust, based on plan participation and enrollment,” says “Medicare Advantage 2012 Data Spotlight: Enrollment Market Update.” The future … Read more

Some managed care companies begin to take a hard look at what’s behind the explosion in costs for radiological services Michael Levin-Epstein High-tech CT, MRI, and PET imaging machines make it possible for physicians to ferret out tumors, uncover ligament damage, and pinpoint blocked arteries, but they are not cheap. That is why radiology costs … Read more

Taking Members From Disconnected to Engaged To engage members and close care gaps, health plans are taking a closer look at member data sets and the analytics that can harness them. Health plans these days are investing time and resources in analytics and investigating new ways to more fully engage with their members. Why? Because … Read more

The National Committee for Quality Assurance hopes to elevate the degree to which quality of care factors into people’s choice of health plans. NCQA is placing health plan report cards on its web site, and it will make customized reports available on employers’ internal network sites later this year. The report cards give users free … Read more

Houston’s MacGregor Medical Association is the kind of practice computer fans extol. Wired to the teeth, the 220-physician multispecialty group has developed its own medical information software, a package so comprehensive that three groups in other cities tap into the MacGregor system to use it. MacGregor’s network links 23 Houston and San Antonio facilities into … Read more

EMPLOYER UPDATE Thanks to a Business Roundtable-sponsored group calling for better outcomes at hospitals, health plans’ lobbying efforts may pay off. Jack McCain Contributing Editor In late 1994, the health columnist for the Boston Globe, Betsy Lehman, died as a result of an overdose of the chemotherapeutic agent she was receiving for breast cancer at … Read more

NEWS AND COMMENTARY CAQH Certification Yields $1B Savings Health plans and providers that adopt national information technology standards can save more than $3 billion in three years, according to a study by the Council for Affordable Quality Healthcare (CAQH). Plans and providers that are certified by CAQH to use its Committee on Operating Rules for … Read more

Embattled Theranos, Inc., has decided to close its blood-testing facilities and reduce its workforce by more than 40%, according to a report in the Wall Street Journal (WSJ). In a statement posted on the company’s website, founder Elizabeth Holmes said: “We will return our undivided attention to our miniLab platform. Our ultimate goal is to commercialize … Read more

They are touted as an alternative to emergency departments. Private companies are seeing an opportunity. But are urgent care centers meeting a demand or creating one? Floor-to-ceiling windows line three sides of the glass and steel front of one of the newest urgent care centers in Massachusetts. In the resort town of Falmouth (winter population … Read more

The turbocharged rush to offer choice to consumers leaves a question in its wake: Choice of what? It turns out that consumers value having a choice in providers more than having a choice of health plans, according to a study by the Commonwealth Fund, which warns that “policymakers should be cautious about embracing the individual … Read more

Will global capitation be the means of reducing HMOs to the status of third-party administrators? Experts differ on that one. But they agree that capitation, in its various forms, is here to stay. Part III of Three Part Series. See Also: PART I : The March of Capitation: Reversed or Just Delayed? PART II: ‘Contact … Read more

Martin Sipkoff The FTC warns that the competition between ‘follow-on’ biologics and the pioneer products is likely to be of the brand-vs.-brand variety MANAGED CARE August 2009. ©MediMedia USA The FTC warns that the competition between ‘follow-on’ biologics and the pioneer products is likely to be of the brand-vs.-brand variety Martin Sipkoff Few industry issues generate as … Read more

Wellmark Blue Cross & Blue Shield finds that technology can enhance doctor buy-in with dramatic results Insurers discovered long ago that tying physician performance to extra income is pretty effective for improving outcomes and controlling costs. One health plan in the Midwest finds that giving clinicians power can also go a long way to improving … Read more

This paper Contrasts two Collections of US-led Post War reconstruction According to Antonio Gramsci’s idea of power, this report asserts that in the aftermath of military success from Japan and Iraq, the US attempted to launch a brand new historical bloc from the occupied nations, ” a historical bloc centred on capitalism as a way … Read more

All the state-of-the-art health care literacy tools go for naught when faced with such ignorance At a time when people make decisions about health care based on input from friends, family, physicians, the Internet, and a myriad of other sources, you can count Charlie Baker as a believer in the positive influence of a steadily … Read more

A commission tasked with President Donald-trump to Handle the Country’s opioid outbreak issued its last report on Wednesday, representing over 50 tips, for example calling for clinicians who prescribe opioids to get training on safe prescribing till they are able to renew their permits together with the Drug Enforcement Administration. (PDF) will not define the … Read more

Name Last modified Size Description Parent Directory 31-Jan-1999 15:58 – 9808.compmon.gif 25-Sep-1998 23:43 51k ../../archiveMC/9808/9808.compmon.pdf 25-Sep-1998 23:43 45k 9808.compmon.shtml 04-Oct-1998 14:15 1k 9808.contents.shtml 04-Oct-1998 14:15 2k 9808.downturn.shtml 04-Oct-1998 14:15 14k 9808.editorsmemo.shtml 25-Sep-1998 23:44 3k 9808.ethics.shtml 04-Oct-1998 14:15 8k 9808.legal.shtml 04-Oct-1998 14:15 7k 9808.negotiate.shtml 04-Oct-1998 14:15 24k 9808.news.shtml 04-Oct-1998 14:15 5k ../../archiveMC/9808/9808.news_docreport.gif 25-Sep-1998 23:45 37k ../../archiveMC/9808/9808.news_riskchart.gif … Read more

Kaiser Permanente physicians in Albany, N.Y., are close to a merger with the region’s largest medical group, a union that would create a group of more than 150 physicians. The Capital Area Permanente Medical Group has been considering its options since Kaiser Permanente sold its New York business to Capital District Physicians’ Health Plan. The … Read more

Human trial expected in October   Paris-based Sanofi(link is external) and its vaccines global business unit Sanofi Pasteur(link is external) have announced a cooperative research-and-development agreement with the Walter Reed Army Institute of Research (WRAIR) on the co-development of a Zika vaccine candidate. According to the terms of the agreement, WRAIR will transfer its Zika purified inactivated virus (ZPIV) … Read more

We ran upgraded systematic literature reviews to 20 Clinical concerns on pharmacologic therapy addressed at the 2015 guidelines, also for 26 brand new queries on pharmacologic therapy, treat‐to‐target plan, and utilization of imaging. We used the Grading of Tips, Assessment, Development and Analysis approach to appraise the standard of signs and formulate tips and demanded … Read more

With All the youngest of these baby boomers hitting 65 By 2029, the range of individuals who have visual impairment or blindness from the USA is predicted to double to over 8 billion by 2050, based on projections on the basis of the latest census statistics and by studies financed by the National Eye Institute, … Read more

Managed Medicare and Medicaid especially struggle to develop improved discharge and follow-up systems While Congress looks to wring billions of dollars out of the nation’s health care system, America’s health insurers believe billions may be saved simply by improving hospital discharges so that patients do not return. Some health plans have been working on this … Read more

Do We Overspend on Health Care, Underspend on Social Needs? Until recently, health plans have all but ignored the social determinants of health Health Plans’ Success Mixed In Managing Cancer Care Programs They too often focus narrowly on the work of oncologists, when a much more comprehensive approach is needed Oy Vey! A Cartoonist’s Take … Read more

Whether or not the public hubbub over CEO salaries at HMOs is entirely justified, it’s clear that managed care plans’ top business decision-makers are pulling in more than their top doctors. A recent survey of the nation’s 22 publicly traded HMOs yielded comparative averages for CEO, chief operating officer, chief marketing officer, chief financial officer … Read more

Numbers tell part of the story of the nation’s opioid crisis. The CDC says 91 Americans die daily from opioid overdoses, which have killed more than 300,000 since 2000—and the death rate is rising. But to John Machata, MD, of Wickford, R.I., some of the numbers have faces. He remembers the call he got not … Read more

Widespread adoption of this technology is inevitable, yet physicians still resist. Various coalitions and initiatives are trying to make adoption easier. Health plans and pharmacy benefit management companies are moving as quickly as possible into the brave new world of electronic prescribing, pushed hard by employers and the federal government. Pharmacists are moving even faster, … Read more

The 4th Annual Oncology Management Summit Chicago, IL June 5-6, 2019 Employer Provider Leadership Seminar Rutgers School of Pharmacy, New Brunswick, NJ June 11, 2019 2019 Medicaid Managed Care Forum New Orleans, LA June 13-14, 2019 2019 Reducing Hospital Readmissions Summit New Orleans, LA June 13-14, 2019 Healthcare IT & Analytics Summit 2019 Newport, RI July … Read more

Despite the seeming Gordian knot of regulations associated with Medicare Part D, health plans figure the benefit-to-risk ratio is squarely in their favor. The labyrinth of regulations notwithstanding, health plans are surprisingly engaged in Medicare Part D. The Centers for Medicare & Medicaid Services received hundreds of applications by the March 23 deadline from plans … Read more

New Jersey would become the fourth state to enact regulations governing distribution of weight-loss drugs, if a state Board of Medical Examiners proposal is approved. The proposal would require that physicians prescribing weight-loss pills embrace a holistic approach to care — take patients’ medical histories, check for diabetes and hypertension, give advice about diet and … Read more

Formularies, one of managed care’s favorite cost-control tools, may not be doing the job, according to a new study led by outcomes expert Susan Horn, Ph.D., senior scientist at the Institute for Clinical Outcomes Research in Salt Lake City. What Horn and fellow researchers discovered surprised them and will surely stun managed care executives: Restrictive … Read more

Co-payments Are meant to de crease alternative party cost on pharmaceuticals, especially those considered as less crucial. But, co payments are correlated with decreased usage of most medicines. Independently insured inhabitants encompass some exposed patient groups such as elderly individuals and very low income classes, who could be particularly prone to drug non-adherence when demanded … Read more

It’s called the Quality Health Care Coalition Act — and it’s one of the most potentially explosive pieces of health care legislation to be introduced this session. But don’t let the name fool you. This bill has to do with collective bargaining, not quality. Introduced by Republican Rep. Tom Campbell of California, the bill would … Read more

New Caution About Risk Adjustment After United Whistleblower Lawsuit UnitedHealthcare has denied allegations that it gamed Medicare Advantage risk adjustment, but other insurers are taking note and might be more cautious. California Dreamin’, But Will It Stay That Way? Medicaid expansion and Covered California’s $100 million-a-year marketing budget have pushed the uninsured rate into the single … Read more

UnitedHealthcare has ditched Silver Sneakers for something it says is better. Other insurers are sticking with it. Either way, wellness is looming large in the MA market. UnitedHealthcare garnered a lot of attention last December when it announced that it would drop Silver Sneakers as an offering in its Medicare Advantage (MA) plans in 2019. … Read more

The first time I encountered cost-effectiveness research was during a stint at the Harvard School of Public Health in the early ’90s (the injection of T.H. Chan into the school’s name came much later). I was a journalism fellow there and then worked as a writer and editor. The details have slid outside my recall, … Read more

To offer superior value in the brave new world of managed competition, doctors must search for compatible allies with whom they can provide collaborative services to achieve economies of scale and make full use of clinical and operational data management. Collaboration is impossible unless the allies talk freely, exploring ways to increase their value and … Read more

What with lawsuits and poor financial performance, 1999 could hardly be termed a good year for HMOs. Despite those setbacks, the some HMO executives seemed to do OK for themselves. Of course, what’s not shown here is how executives in other industries fare while in the trough. (Remember all those articles about golden parachutes during … Read more

The CMO of the nation’s largest pharmacy benefits manager says that the company’s mission has broadened. One new area of focus: worker productivity. Alan T. Wright, MD, MPh, is at the center of efforts by the nation’s largest pharmacy benefits manager, AdvancePCS, to redefine itself as a “health improvement company.” Built through a series of … Read more

Reinsurance, once a sleepy part of managed care, is changing. Provider stop-loss is where much of the actions is, but health plans are also affected. Managed care executives call it reinsurance. Provider and physician groups usually call it stop-loss or provider excess. But the core idea is the same: buying some insurance protection against those … Read more

John Marcille Editor The Catalyst for Payment Reform finds that only 10 percent of care is paid through new methods, but its executive director says shared goals and incremental change will make a difference With UnitedHealth Group’s recent study finding that the United States could save between $200 and $600 billion in the next 10 … Read more

Within a few years, there may be only 30 DM companies left, says one expert. HMO customers want vendors to handle more than one condition. At the time L. Peter Smith jumped into the disease management field six years ago, prospective customers in managed care had a simple expectation: Prove what you’re pitching. By establishing … Read more

The mind of the Drug Enforcement Administration is visiting China this week to Go over fighting earnings of synthetic medications , such as fentanyl,” CNN reports. Acting Administrator Chuck Rosenberg may additionally talk new psychoactive compounds and moneylaundering tasks when he meets Chinese officials. After China Barred 116 artificial medication in 2015, the USA watched … Read more

Not only is the program expected to be short on cash, but many patients may not be able to afford even the subsidized rates John Carroll Contributing Editor The Centers for Medicare and Medicaid Services has released new rules to guide the creation of state-based health plans to cover high-risk people with no other coverage, … Read more

Managed care companies may benefit from swelling enrollment, but some questions remain unanswered By all accounts, when Congress put $87 billion in new federal Medicaid subsidies in the stimulus bill, it prevented some bone-deep budget-cutting in states that have watched tax revenue plunge with growing alarm. Under the law, states that agree to take the … Read more

Hallucinations and delusions are common in people with Parkinson’s disease, but many antipsychotic drugs are either ineffective or worsen motor symptoms. With phase 3 testing of pimavanserin (Nuplazid) completed, Acadia Pharmaceuticals hopes to change that. In the so-called -020 Study, which enrolled 199 patients with Parkinson’s disease psychosis (PDP), pimavanserin met its primary endpoint in … Read more

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Increasingly sophisticated imaging and lab tests, along with campaigns to encourage screening tests, have meant that cancers and many other conditions are discovered much earlier in the disease process. Catching a disease early can mean more effective and less costly treatment. But there’s growing recognition that moving disease recognition upstream can result in overdiagnosis—finding an … Read more

The health care economist says that consumers ought to share in the savings from making the right choices. Insurers, providers, and hospitals should make sure that options exist. The future of market-oriented health policy and practice lies in ‘managed consumerism,’ a blend of the patient-centric focus of consumer-driven health care and the provider-centric focus of … Read more

Pharmacists have long wanted more opportunities to contribute and to be respected for their abilities. Behold the patient-centered medical home. PharmDs want to move beyond counting pills to medication therapy management, immunizations, lab tests, and medication visits. The American Pharmacists Association (APhA) sees an opportunity to achieve this goal by latching onto a popular health … Read more

Covering the full cost of combination therapies to prevent patients from having a second myocardial infarction might initially cost health insurers an additional $550 per patient, but then could wind up saving them an average of $1,731 per event, according to a study published in Health Affairs. But insurers may be hesitant to offer full … Read more

New York state would seek a waiver from the Centers for Medicaid & Medicare Services to contract with health plans to cover people who are eligible for both Medicaid and Medicare, under a new proposal. The state’s 700,000 dual-eligibles consume about 45 percent of Medicaid and 41 percent of Medicare spending. A proposal by the … Read more

Simponi Aria, a fully-human anti tumor necrosis factor (TNF)-alpha therapy, has been approved in 2013 for its treating mildly to severely active rheumatoid arthritis symptoms. The FDA’s enlarged concessions were encouraged by statistics in the Phase 3 Multicenter, randomized, doubleblind, multiple-choice research (GO-VIBRANT and GO-ALIVE) which comprised p 600 patients. Research workers were randomized to … Read more

States have increasingly turned to managed care plans to care for Medicaid enrollees more economically than traditional programs. Percentage of Medicaid enrollees in managed care, 1996-2004 Source: Centers for Medicare & Medicaid Services

Back in February and July 2015, the irs issued recommends covering lots of topics in regards to the Cadillac Tax, also requested comments on the probable procedures which may eventually be integrated into proposed regulations. As the taxation has been originally non-tax allowable, the December 2015 changes imply it’s going to be tax exemption for … Read more

The next time Kaiser Permanente comes to CalPERS with its hat in its hand, it may have to be very persuasive. Kaiser’s HMO turned a $56 million first-quarter profit — its first quarter in the black in two years. Kaiser’s turnaround — it lost $881 million in 1997 and ’98 — is due to premium … Read more

His concepts have been enormously influential in the evolution of the health care system, but the results aren’t what he expected. Now he has a new program for saving the system from itself. Paul Ellwood is losing his patience. The man who coined the term health maintenance organization and helped craft the market-based managed competition … Read more

Health savings account (HSA) insurance plans continue to thrive, with more than 11.4 million Americans covered, up 14 percent from last year alone. HSAs were launched in January 2004, authorized by the Medicare Prescription Drug Improvement and Modernization Act of 2003. Since then, America’s Health Insurance Plans (AHIP) has conducted annual surveys to keep track … Read more

The Evolving Biosimilars’ Landscape Explore the complexities of the biosimilars’ landscape, such as naming, interchangeability and substitution, differences in the manufacturing processes, as well as the approval pathways & FDA guidelines for biologics, including draft guidance on biosimilars. USA-BIO-106112

The sky is not falling. Premiums will rise, but not nearly so high as some have predicted. Paul Ginsburg, a Harvard-trained health economist, for the last couple of years has bucked the dire predictions that health care costs would soar, arguing that the accounts such warnings were based on were, in fact, exaggerations. Crunching numbers … Read more

Managed Medicare and Medicaid especially struggle to develop improved discharge and follow-up systems While Congress looks to wring billions of dollars out of the nation’s health care system, America’s health insurers believe billions may be saved simply by improving hospital discharges so that patients do not return. Some health plans have been working on this … Read more

COVER STORY With the Affordable Care Act taking effect in just six months, unfinished regulations, obscure reform mandates, and unintended consequences create a potential minefield for payers Michael D. Dalzell Senior Contributing Editor Ask people “What’s the most incomprehensible thing you’ve ever read?” and you’ll get a lot of different answers. Finnegan’s Wake. Your bundled … Read more

Would Steve Jobs Have Agreed With an ACO Movement? Submitted by Paul Terry on Thu, 2012-01-12 11:05 Having just finished reading Walter Isaacson’s brilliant rendition of Steve Jobs’s life and career, I’ve considered whether there are health care marketplace lessons to be garnered from his central casting in the extraordinary tech wars for primacy over the past … Read more

Drug Non-adherence is a significant general health concern, affecting health effects and general medical care expenses. This review considers that the latest improvements from adherence research having a focus on the effect of drug adherence on medical care costs in america medical system. We clarify the size of the non-adherence problem and associated expenses, using … Read more

Aetna has seen the future and it is performance measurement. The insurer last month said it would expand a program that offers a network of specialists who have shown that they adhere to best-practice guidelines. That program, called Aexcel, is for employers that use Aetna as third-party administrator. These companies have the option of offering … Read more

About 1 in 6 Americans report paying more than 10 percent of their total family income for health insurance premiums, says the latest report from the Agency for Healthcare Research and Quality. Of those with employer-sponsored insurance, 16 percent spend 10 percent or more of their income on premiums and out-of-pocket expenses. Of those with … Read more

Increased understanding of the pathophysiology of lupus has resulted in a promising therapy for this complex disorder One of the most difficult-to-treat conditions is systemic lupus erythematosus (SLE), commonly called lupus by both professionals and laypeople. Because of this disease’s complexity, there hasn’t been a new drug approved for it for nearly 50 years. But … Read more

Do We Overspend on Health Care, Underspend on Social Needs? Until recently, health plans have all but ignored the social determinants of health Joseph Burns Contributing Editor When a homeless patient and her disabled son had no way to get to a doctor last winter, William A. Gillespie, MD, sent a car service to pick … Read more

Harvard public health investigators Douglas Jacobs and Benjamin Sommers, MD, analyzed that the formularies of all 4-8 silver market plans in 12 nations, also found that 12 of those plans set HIV medications in a specialization level in which associates need to pay for no less than 30 percentage of their medication’s cost. “The gaps … Read more

Gene therapy are in an inflection point. Recent victories in hereditary medication have paved the trail for a wider instant tide of treatments and placed the foundation for nextgeneration technologies. The last five years have experienced a renaissance in the area of cell and gene therapy along with also the very first approved remedies following … Read more

Many currently marketed antidepressants will be falling off the patent cliff soon. Nonetheless, the antidepressant market is set for steady expansion, according to Datamonitor, a drug information company. The company compiled data from seven major markets for this drug category and found total sales to be $10.9 billion in 2010. By 2020, the market is … Read more

As with so much else in health care, observing protocols, analyzing data, and rethinking benefit designs are important. Also available in PDF It’s no less true for being obvious: Educating and managing patients with chronic conditions is an effective way to stabilize overall health care costs. Now it appears that health plans are beginning to … Read more

Medicare demonstration projects and reform legislation should lead to ‘no outcome, no income’ policies, this population health expert says John Marcille When David B. Nash, MD, MBA, calls health care reform legislation a full employment act for the faculty and graduates of Thomas Jefferson University’s two-year-old Jefferson School of Population Health, he means it. Physicians … Read more

After Ohio uncovered huge spreads, other states have taken a hard look at spread pricing in their Medicaid programs. U.S. senators and CMS are also getting into the act. If some lawmakers have their way, PBMs will no longer be able to play the spread. A small but growing number of states are scrutinizing the … Read more

Drug exclusivities serve help to give insurance from contenders to inventive medications and biologics by conceding market section for a restricted timeframe. Subsequent to entering the US market, pharmaceu-tical items can profit by an assortment of exclusivities, through the administrative interaction or the patent framework, through the US Patent and Brand name Office or a … Read more

When considering somebody carrying a drug for migraines, then you might imagine them popping a pill. Now, there exists a syringe. Injectable drugs aren’t as rare nowadays. Most medications for psoriasis The main reason is the medication they take could be destroyed from our gut, therefore it can not be obtained orally. What’s special about … Read more

U.S. health care spending to climb 5.3% in 2018, agency predicts Prescription drug costs are expected to see the fastest annual growth among health care expenditures over the next decade, the Centers for Medicare and Medicaid Services (CMS) predicts, rising an average of 6.3% a year due to higher drug prices and more use of … Read more

Simplistic, for sure. But a movie pitting a man with modest income against the big bad managed care plan has drawn attention to the enormous cost of transplants and the difficulty of matching organs and recipients. Marlene Piturro Managed care is known to have a poor image in the popular media, although it isn’t particularly … Read more

A point-counterpoint debate with Michael Jacobs, RPh, and Wayne M. Lednar, MD, PhD Topics What Will Be the Effect of CDHPs on Overall Health? What Will Be the Effect of CDHPs on Health Care Costs? Thoughts for the Future Biographic sketches for Mr. Jacobs and Dr. Lednar Consumer-directed health plans (CDHPs) have recently emerged as … Read more

NHS England includes a duty to define those health care services That It believes a federal price ought to be properly used, and also NHS Improvement gets the obligation to establish this price. The nationwide Tariff defines principles regulating not merely the way nationwide put pricing will continue to work, but also how localized price-setting … Read more

Health insurers in Kentucky can now set rates for individuals that take health status into account. Under the new law, an individual’s health insurance premium can vary up to 35 percent from a state-set index rate. The system is expected to lead to lower rates for healthy adults and higher rates for sicker individuals. So … Read more

Child vaccinations, tobacco-cessation counseling and treatment, and screening for vision impairment in the elderly are the most important preventive services — from the standpoints of cost-effectiveness, reducing the necessity of treatment for illness, and averting injury — according to rankings in the American Journal of Preventive Medicine. Fewer than half of those who could benefit … Read more

Percentage of business owners with fewer than 200 employees who say that the following are very important when choosing health coverage: Color chart SOURCE: HEALTH BENEFITS OF SMALL EMPLOYERS, KPMG PEAT MARWICK FOR THE KAISER FAMILY FOUNDATION, 1999

Transparency in contracting is a great thing, but it takes vigilance to keep it from clouding over Linda Cahn “What’s in a name? That which we call a rose by any other name would smell as sweet.” Juliet was speaking of Romeo, and expressing a universal truth. Unfortunately, pharmacy benefit management companies (PBMs) would like … Read more

Fifth agency nod since drug’s 2006 launch The FDA has approved ranibizumab (Lucentis, Genentech) 0.5-mg injection for the treatment of patients with myopic choroidal neovascularization (mCNV), a complication of severe near-sightedness that can lead to blindness. Ranibizumab is the first FDA-approved anti-vascular endothelial growth factor (VEGF) therapy to treat mCNV in the United States. This … Read more

By John La Puma, M.D. Two years ago, ethical issues in alternative medicine seemed hard to recognize. Alternative medicine was just starting to make medical headlines — the first academic centers and fellowships began, elective medical school classes surfaced, outpatient pharmacies stocked up on zinc and echinacea. So two years ago, I used Jonsen, Siegler … Read more

Bayer’s Bestselling naturopathic medication Xarelto has also demonstrated effective in preventing heart attacks and strokes in patients afflicted by certain sorts of cardiovascular disorder, the business said on Wednesday. The Medication is prescribed to prevent fractures in patients having irregular heart clots and beats, among other applications, yet to expand its usage Bayer continues to … Read more

More companies are offering less coverage — or none at all. Even those that offer coverage find that more of their workers choose not to sign up. Don’t miss: Strategies to regain enrollees in the employer-sponsored market by Peter Kongstvedt, MD For the past generation, Walter Brock has been the go-to guy at Capital Valve & Fitting … Read more

Are you dreaming of a world where mass cancer screenings are discarded as wasteful and personal genetics and ‘big data’ inform individually targeted therapies? Wake up — that world is fast approaching. It may seem paradoxical for the dean of the Jefferson School of Population Health to say this, but perhaps we do not need … Read more

Health insurers have to cover eight preventive health care services at no cost under the Affordable Care Act, and they are not thrilled, according to the plans’ lobbying group. “Broadening the scope of mandated preventive services that go beyond or conflict with the current evidence-based guidelines will increase the cost of coverage for individuals, families, … Read more

The recent U.S. Supreme Court decision offers a nice breather, but executives should not let down their guard, as an Illinois ruling shows. By Neville M. Bilimoria, J.D. HMOs should not delude themselves about the U.S. Supreme Court’s June 12 ruling that patients cannot sue a health plan just because it offers physicians financial incentives … Read more

A Physician Takes Umbrage at Al Lewis’s ‘Treatment Trap’ I want to respond to the negative experience that Al Lewis details in his March 2014 Viewpoint “My Own Trip Into the Treatment Trap … A Cautionary Tale” (http://bit.ly/TreatTrap). While I agree with some of his comments, I feel that he oversimplifies the issues, doesn’t consider the … Read more

If a Brand new cure for rheumatoid arthritis symptoms came, adverts called it a”unique” break through which will”alter expectations” for physicians and patients. Yet countless individuals carrying Actemra have expired out of these difficulties, And so a lot more have suffered injury. STAT examined a lot more than 500,000 side effects reports on autoimmune arthritis … Read more

Legislative Onslaught May Force Conversion to Universal System Every politician seems to have a plan to reform health care. One expert says that all the attention invites trouble. COVER STORY Health Care Report Cards: Who’s Paying Attention? Health care report cards seem to be everywhere — except in the hands of smaller employers when they … Read more

Although the price difference between procedures performed in the United States and in developing countries might suggest that U.S. payers could gain if they extend their coverage to include treatments abroad, there are a number of factors holding back the flood of medical travelers. They include the inaccessibility of networks of providers in some medical-travel … Read more

Cardiovascular disease (CVD) is less of a killer than it used to be in the United States, but the costs associated with the disease are expected to double by 2030, according to the American Heart Association’s 2017 Heart Disease and Stroke Statistics Update. In 2014, the age-standardized death rate attributable to CVD was 220.8 per 100,000, … Read more

Subscribe to Our Newsletters Monthly table of contents Be notified as each issue of Managed Care is available online. Biweekly newsletter Recent topics have included: ACA popularity spike, feisty ACO debate, Google eyes population health, & Avalere sizes up future of AHPs ACA jenga, PBMs toot their horns, the Bon Secours-Mercy merger & what’s next … Read more

An estimated 127 million Americans––one in two adults––are affected by a musculoskeletal condition, and these disorders cost an estimated $213 billion in annual treatment, care, and lost wages, according to a new report issued by the United States Bone and Joint Initiative (USBJI). The report outlines the prevalence and projected growth of musculoskeletal disorders in … Read more

Will the electronic revolution overthrow managed care? Not necessarily, but it may help define a new role for MCOs not far in the future. Consultant and author Peter Boland is an E-commerce expert, and has been a close observer of the managed care landscape for more than 20 years. He is president of Boland Healthcare, … Read more

Long before the Joint Commission on Accreditation of Healthcare Organizations required an institutional ethics mechanism, before bioethics committees were a twinkle in the 1975 Quinlan court’s eye, and even before the medico-moral committees of 1940s Catholic hospitals, there was fraud, abuse and waste. And long before the Tuskegee experiment ended in the 1970s, before Beecher’s … Read more

Rising rates bring focus on self-insured plans Initial 2010 HMO premium rates will increase by 11.8 percent — consistent with last year’s projected rate increases and down from 13.2 percent in 2008, according to Hewitt Associates, a human resources consulting company. This increase is fueling greater interest in self-insured plans and other strategies to hold … Read more

Evidence-based clinical tests from operation are usually faced with scepticism by the healthcare staff, specially just because a confinement of no cost decisionmaking in therapy will be expected. Contemplating that medication isn’t simply natural science, but could as well be recognized as societal science or art, non-steroidal medication  may possibly cause a oversimplified and rigid … Read more

Doctor Sanjaya Kuruppua researcher by the Monash Bio Medicine Discovery Institute More over, doctor Kuruppu was clearly one of just 20 boffins worldwide to gain these NIH grants. Doctor Kuruppu is directing a team exploring a publication molecule based on snake venom which holds promise as a means of countering the noxious protein’amyloid-beta’, that will … Read more

Three quarters of health care leaders believe increased transparency — the public reporting of quality and pricing by name of hospital, physician practice, or health care provider — is essential to improve the performance of the United States’ health care system, according to the Commonwealth Fund/Modern Healthcare Health Opinion Leaders Survey. Improved transparency can affect … Read more

Can Health Plans Change Unhealthy Behavior?    23 Smoking, fat-filled diets, endless gazing at the tube–they’re disastrous for health and bad for the bottom line. So physicians and managed care organizations are grappling with ways to put more life into the American life style. Gain the ‘Quality’ Edge In Competing for Contracts    39 Managed care contracts are most … Read more

The government committee charged with helping health plans and providers choose best treatments suggests 100 areas of interest One could say that the government, in its backing of comparative effectiveness research, wants to compare apples and oranges. The Committee on Comparative Effectiveness Research Prioritization released 100 topics that it says should be the focus of … Read more

Build a National Network One Region at a Time Regional health information organizations are getting more scrutiny on Capitol Hill. They might hold the key to funding a national online network that links providers. Support Grows for Establishing National Clinical Trial Registry Stakeholders are pushing for a national clinical trial registry, and efforts by UnitedHealth … Read more

By some counts misdiagnosis leads to up to 80,000 hospital deaths each year—and results in billions in wasted medical spending. Lack of feedback and miscommunication are among the causes. Researchers, advocates, and others are pushing for changes and ‘diagnostic excellence.’ About 60% of newborns have jaundice, and her baby’s doctors and nurses recognized that Sue … Read more

Nearly 9-2 million eligible Americans failed to vote at the 20-16 elections. From the 2014 mid term elections, around 143 million eligible Americans did not vote, signaling the best voter involvement in 72 decades. For the world’s democracy to operate correctly and also for government to offer acceptable representation, all of eligible Americans have to … Read more

EDITOR’S MEMO John A. Marcille In the mid-1980s, when Senior Editor Frank Diamond was working for a newspaper, he wrote a profile of a local caricaturist. As part of the interview, the subject rendered an outsized version in ink of Frank. The picture shows the cub reporter sporting a huge smile, pencil tucked behind his … Read more

In a familiar cartoon, a professor writes long, learned equations on a blackboard. To connect the profundities on either end, he writes in the middle, “Then a miracle occurs.” IPAs, done well, are the miracles that connect the ends of health care. When you look at a brick wall, what do you see? Most people … Read more

The insurer’s CEO explains the company’s approach to growth, how a team-based system nurtures better care, and why he thinks Medicare for all might not work. We interviewed Marc Harrison, MD, shortly after he became CEO and president of Intermountain Healthcare in Salt Lake City. Now, three years later, we thought it would be a … Read more

When drugstore goliath CVS announced its $69 billion bid to buy Aetna in November, it was largely seen as a ploy by CVS to stave off Amazon, which seems to be planning an incursion into the pharmacy business. But for the health insurance industry, there’s something far different—though equally momentous— going on here. The presence … Read more

Follow this link to PDF version By mid-1999, the HMO-enrollment growth rate had hit its lowest level of the decade — 2.6 percent from July 1, 1998 to June 30, 1999. A closer analysis may be even more troubling for HMOs: From Jan. 1 to June 30, 1999, total enrollment actually dropped for the first … Read more

The British Medical Journal this year published a comparison of Kaiser Permanente and the National Health Service, concluding that health care “costs per capita in Kaiser and the NHS are similar to within 10 percent and that Kaiser’s performance is considerably better in certain respects, particularly access to specialist diagnosis and treatment, and hospital waiting … Read more

The California Medical Association (CMA) says it has found more than $1 billion that can be spent on health care in the state. And it’s all in the hands of a short list of the state’s for-profit health plans. The physician group has been championing a bill that would require health plans to spend a … Read more

Will States Ban Capitation? Salem, Ore., ophthalmologist Gordon Miller wants to ban capitated payments to physicians. His ballot measure apparently didn’t light up the skies, but some wonder if a brushfire could yet spread. Chuck Appleby Is Paying Physicians By Capitation Wrong? The concerns of Oregon anti-capitation crusader Gordon Miller draw a surprising degree of … Read more

NCQA hopes its revamped accreditation process and documents modeled on Consumer Reports will mean more use by employers and the public. Most folks who have shopped for a car have seen, at one time or another, Consumer Reports’ simple visual method of rating various aspects of vehicles. I first saw the magazine’s familiar bubbles in … Read more

COVER STORY PPMs, HMOs: Sometimes, a Perfect Match  19 Physician practice management companies’ power is growing. PPMs may be good partners for HMOs, but are they treading on plans’ turf? Are PPMs Beauties … or Are They Beasts?  26 In a moderated discussion, a PhyCor executive and a practice management consultant trade impressions on the pros and … Read more

The National Committee for Quality Assurance introduced several new measures in HEDIS 1999, many focusing on management of chronic conditions. Results of these first-year measures, published in NCQA’s State of Managed Care Quality 2000, put a stake in the ground in terms of how well health plans care for members with costly chronic conditions — … Read more

Attempts to improve efficiency often involve controlling utilization, but Geisinger Health Plan thinks it has a better approach “Historically health plans have poked at the delivery system from the outside to improve efficiency and value,” says Richard Gilfillan, MD, who is CEO of the Geisinger Health Plan. “We said we’ll try precertification, or radiology benefit … Read more

Pulmonary embolism and profound Venous thrombosis would be both main indications of adrenal thromboembolism, that’s the next most popular lifethreatening cardio vascular illness from the USA. Anticoagulation may be your mainstay of all VTE therapy. Unfractionated heparin can be useful when an individual is hemodynamically unstable or gets acute renal insufficiency, higher bleeding risk, hemodynamic … Read more

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Urged on by employers, the Big 3 are going beyond traditional pharmacy benefit management, stressing consumer interactions and disease outcomes and threatening the existence of captive PBMs While the 14-15 percent annual increases in drug expenditures of the early 2000s have settled down to around 5 percent, there are unsettling forces at work within the … Read more

National professional organization is updating, revamping, and expanding programs   The membership of the American Academy of Pain Management has voted to change the organization’s name to the Academy of Integrative Pain Management. For the last 28 years, the Academy was the only national professional organization dedicated to advancing the integrative pain care approaches that … Read more

Sophisticated businesses discovered that the key to retaining a competitive edge is never to compete . On the contrary, it will be always to fix to put themselves apart from the contest. That is just how high businesses operate. Rather than after in The course of present competitors, they stipulate their company and also distinguish … Read more

A Conversation with Michael E. Porter, Phd, and Elizabeth Olmsted Teisberg, PhD “How could the largely private U.S. health care system, characterized by arguably more competition than any other health care system in the world, be performing so poorly?” Michael E. Porter, PhD, and Elizabeth Olmsted Teisberg, PhD, set out to provide a new way … Read more

Urged on by employers traumatized by costs, health plans are renewing their interest in prior authorization, but using a lighter hand The truth is that prior authorization never died. Instead, it has evolved. “As a cost saving technique, it didn’t fail. It actually saved money,” says Glen Stettin, MD, vice president for clinical products at … Read more

A National Judge in Delaware has announced that a jury decision requiring Gilead Sciences Inc to cover a record $2.54 million due to its own hepatitis C medication Sovaldi and Harvoni infringed a patent held by rival Merck & Co Inc.. The Verdict was the largest in a U.S. patent instance however U.S. District Judge … Read more

The biggest for-profit and not-for-profit MCOs have been through rough times recently. How have their corporate cultures changed? Companies have separate identities, as distinct as you or me. Like us, they have histories. Events change them and, often, they influence events — especially if they are the two dominant players in their industry. The Kaiser … Read more

Revenue in pediatric medical practices has not kept pace with cost increases, according to the Medical Group Management Association Survey for Pediatric Practices: 2004 Report Based on 2003 Data. Groups with nine or more physicians report greater revenue per doctor than smaller practices. The large groups reported revenue, after operating costs, of $226,489 per full-time … Read more

The FDA has granted seribantumab (Merrimack Pharmaceuticals) fast track status for development in patients with heregulin-positive, locally advanced or metastatic non–small-cell lung cancer (NSCLC) whose disease has progressed after immunotherapy. The global SHERLOC trial is evaluating seribantumab in combination with docetaxel or pemetrexed in heregulin-positive patients with NSCLC. The data from this study will be … Read more