There’s a new player in quality measurement: the National Forum for Healthcare Quality Measurement and Reporting. Though the Quality Forum, as it calls itself, has yet to develop a framework for measurement, the group wants to help users make sense of quality data. The group’s ambitious goals: To measure quality of health plans and physicians … Read more

A Couple of months past Linda Cahn was Considering the Way the giant Could Change the present PBM business version of convoluted contract speech, secret side prices, opaque pricing arrangements, and so on. “A Wal Mart, Costco, or even Amazon could make a Really transparent PBM,” Said Cahna PBM adviser and also an ardent critic … Read more

Patients are more and more demanding that urologists use robotic surgery for prostatectomies, but insurers are hesitant to provide coverage, claiming that there is insufficient evidence that the technology improves outcomes. UnitedHealthcare, for example, in its medical policy manual, says, “When compared to conventional procedures, the use of robotic surgical systems provides no additional health … Read more

Reform legislation passed in MA at 2006. RomneyCare geared toward reform health by providing all of MA residents with affordable excellent medical insurance. Additionally, it offered additional protections to MA occupants for example the preservation of health care when changing employers or any time they confronted financial problems. The concept being that citizens of the … 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

With the presidential campaign heading into the home stretch, Bush administration officials are scrambling to reap political dividends from what they consider to be one of their big achievements — Medicare reform. Kevin Keane, a spokesman for the Department of Health and Human Services, tells the Wall Street Journal that the problem is that many … Read more

Stem Cell Therapy Shows Promise in Spinal Cord Paralysis Progenitor cells improve upper-extremity motor scores   Positive interim efficacy data have been reported from an ongoing phase 1/2a trial of AST-OPC1 (Asterias Biotherapeutics), an oligodendrocyte progenitor population derived from human embryonic stem cells, in patients with complete cervical spinal cord injury. While it is still … Read more

With hospitals facing penalties for readmissions, there perhaps has never been a better time for insurers to address this vexing problem Frank Diamond Managing Editor Hospitals are under the gun, and insurers can help them — and themselves as well. Beginning in October 2012, hospitals will lose money for readmissions of Medicare beneficiaries within 30 … Read more

Washington Watch In an election year, the political hot buttons — the Patients Bill of Rights and a Medicare prescription benefit, and maybe the issue of medical errors — are sure to get a lot more attention than such mundane things as laws that would address potential kickbacks. So little attention has been focused on … Read more

Everyone knows about the perverse incentive of fee-for-service medicine, but that hasn’t had much effect on its use Every year, physician groups take doctors’ temperature on the issue of pay, and every year, they are feverish. Professional associations such as the Medical Group Management Association annually hold up low average compensation increases as a key … Read more

Post-operative Anxiety is a significant problem, particularly in rectal operation. Our statistics imply sub-optimal pain control after total knee arthroplasty. This analysis assessed a sufentanil enhancement pill to maximize post operative pain therapy. Zalviso as conventional treatment was compared using a cohort receiving oxycodone immediate discharge and Oxy extended-release and a second receiving Oxy instantaneous … Read more

Safetynet Even the Affordable Care Act expects that insurance expansions increase Safetynet hospitals’ earnings, also reduces DSH obligations consequently. We analyzed the effects of this ACA’s Medicaid DSH discounts on California public associations’ financial equilibrium by estimating the way that overall DSH costs will vary as a consequence of motor insurance expansions and also the … Read more

There’s some evidence that providing financial benefits for healthier behaviour helps employees reach shortterm health objectives. Further evidence is necessary to verify longterm consequences. Rewards increase program involvement and certainly will help employees reach shortterm health aims in a few conditions. Workplace interventions offering financial rewards for weight loss reduction could lead to modest weight … Read more

Some leaders in health care say measurable improvements in public health could occur if physicians would use their bully pulpit a bit more. The Washington-based Center for the Advancement of Health released a report, supported by the Robert Wood Johnson Foundation, suggesting that if physicians and other health care professionals took just a little time … Read more

This positive situation was merged in relation to greater safety and accessibility in the 1990s, once the very first recombinant coagulation factors are made. This meant that, as opposed to just treating opiate bleeding events, prophylaxis regimens can possibly be used as a preventative measure. Following demonstration of its own excellence from the framework of … Read more

Why put impediments in the way of a physician you’re offering to take into the practice? The productivity bonus can work against you both. It’s Time To End The Productivity Bonus! In some locations it’s becoming difficult to attract people to practices that wish to replace physicians or to grow. Maybe these practices should make … Read more

Abuse risk significantly reduced compared with MS Contin Two FDA panels––the Anesthetic and Analgesic Drug Products Advisory Committee and the Drug Safety and Risk Management Advisory Committee––have recommended the approval of Arymo ER (Egalet Corporation), an abuse-deterrent, extended-release, oral morphine formulation. If cleared, the product will be indicated for the management of pain severe enough … Read more

Spending on endocrine and diabetes therapies could surge nearly 70 percent in the next two years, according to Medco Health Solutions. Diabetes treatments were the second leading contributor in total dollars to prescription drug spending growth in 2006, trailing only cholesterol drugs. Spending on diabetes treatments increased 14.5 percent from 2005 to 2006, and the … Read more

Six large employers have pooled resources to offer a low-cost, limited-benefit health plan for workers who would otherwise be uninsured. The companies are IBM, Sears, General Electric, Avon Products, Federal-Mogul, and EMC, a computer storage company. They’ve started a company called HR Policy Association that is being administered by UnitedHealth Group. “Because our health system … Read more

Name Last modified Size Description Parent Directory 02-Nov-2000 10:02 – ../../../archiveMC/9711/9711.compass.pdf 17-May-2000 12:19 155k ../../../archiveMC/9711/9711.outlook_charts.gif 17-May-2000 12:20 41k ../../../archiveMC/9711/9711.compmon.gif 17-May-2000 12:19 38k 9711.qnaellwood.shtml 17-May-2000 12:21 32k 9711.compass.reportc..> 17-May-2000 12:19 30k 9711.compass.regions..> 17-May-2000 12:19 28k ../../../archiveMC/9711/9711.outlook.pdf 17-May-2000 12:20 27k ../../../archiveMC/9711/9711.compmon.pdf 17-May-2000 12:19 26k ../../../archiveMC/9711/9711.medstat_chart.gif 17-May-2000 12:20 25k 9711.capitation_part..> 17-May-2000 12:17 19k 9711.medicare_suppl…> 17-May-2000 12:20 19k 9711.medicaid.shtml … Read more

This Analysis Analyzed financial Statistics Recorded by Florida hospitals Concerning prices, charges, and earnings associated with imaging providers. Diagnosis, stratified by cost centre, analyzed the results of bed size, ownership, education status, and rural or urban status on both indices. The imply working charge and expense per process had been Together with of four methods, … Read more

The front page of the New York Times on Sunday, Sept. 5, carried a report that suggested that former Surgeon General C. Everett Koop’s reputation for integrity and honesty is being tested by his relationship with DrKoop.com, of which he is president. What are Koop’s alleged violations? His contract with DrKoop.com called for pocketing 2 … Read more

To appraise a more collaborative version that incorporates secondary attention aid in to overall training, targeting the principal health issues of patients having longterm ailments. The version was analyzed in two general techniques in a place of high deprivation. Exotic patients were users of their Middlemore Hospital Mature Medical Service. Model elements contained nurse home … Read more

MANAGED CARE June 2006. ©MediMedia USA John Marcille We usually leave concern about consumers to consumer publications. At least that’s the official position. Many times at story planning meetings, we’ve killed ideas when we started to say something like, “This is a shame for the poor patients who. . . .” You can fill in the blanks … Read more

The move toward value-based payment for physicians is unfolding ever so slowly. Some say it is doomed to fail and that fixing the Medicare fee schedule would make more sense. With all the talk about value-based payment models taking over health care, it would seem the system has already flipped over from its traditional a … Read more

When drug manufacturer coupons make members’ costs for brand drugs equal to generics — or less — health plans, employers, PBMs, and members pay a price Health plans that are trying to control their prescription coverage costs must act as if they are engaged in the game of whack-a-mole: They must be continuously ready to … Read more

Health plans should look into why medical centers that spend the most per capita don’t necessarily deliver the best care Health plans need to find some way to insert themselves into the conversation when hospitals they contract with consider whether to launch building programs to add beds or attract physicians, says one of the authors … Read more

Traditional Behavioral Health Treatment Falls by the Wayside Health plans required not to discriminate against members with mental disorders find that many providers have modernized their methods New services, new ways of delivering them, and new ways of managing insurance benefits for mental health and substance abuse disorders are transforming the behavioral health sector. Long-term … Read more

Name Last modified Size Description Parent Directory 04-Jan-98 21:46 – MC6904.few_workers.gif 16-Mar-97 22:43 10k ../../archiveMC/9604/MC9604.awp.gif 16-Mar-97 22:43 9k MC9604.awp.shtml 18-Dec-97 11:10 14k MC9604.clause.shtml 16-Mar-97 22:43 12k ../../archiveMC/9604/MC9604.compmon.gif 16-Mar-97 22:44 13k MC9604.compmon.shtml 16-Mar-97 22:44 2k MC9604.contents.shtml 09-Dec-97 00:52 3k ../../archiveMC/9604/MC9604.cover.jpg 16-Mar-97 22:44 14k MC9604.editorsmemo.sh..16-Mar-97 22:44 3k MC9604.employer.shtml 16-Mar-97 22:44 5k MC9604.ethics.shtml 16-Mar-97 22:44 8k MC9604.gatekeeper.shtml16-Mar-97 22:44 … Read more

Suffering, empathy, competition, the patient experience. Thomas H. Lee, MD, Press Ganey’s chief medical officer and a member of our editorial board, connects some big ideas in his new book, An Epidemic of Empathy in Healthcare.   I’m curious about the genesis of the book. What prompted you to write it? You’ve known me in … Read more

Leading Through Contradictions Submitted by Paul Terry on Thu, 2012-08-23 12:17 I have long held that leaders can’t fake authenticity. When you’re passionate about your vision, it is felt by others whether they support you or not. It’s a realization that has been easy to come by because I’ve had so many great mentors. One … Read more

Medical malpractice insurance premiums continue to rise, even as some states place caps on non-economic damages, according to a survey by Weiss Ratings. In reviewing the effect of tort reform on medical malpractice, Weiss notes that in 19 states that implemented caps between 1991 and 2002, physicians suffered a 48.2 percent jump in median premiums, … Read more

When the Centers for Medicare and Medicaid Services decided to deny coverage (and therefore, payment) for computed tomography colonography (CTC) in February, it set off a firestorm of debate among imaging advocates, providers, payers, and consumers. Traditional colonoscopy has been the gold standard to screen for colon cancer. It can be uncomfortable or inconvenient. CTC, … Read more

Weight or fat loss surgery is Meant to Offer weight reduction adequate to Decrease morbidity and Mortality hazard and improve clinical conditions when less invasive procedures of weight loss, namely Physician supervised weight reduction programs or obesity disease control programs, never have been Surgery combined with their various federal bariatric surgery certificate programs right to … Read more

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 dinner. The moral of … Read more

Ninety-four percent of physicians have some type of relationship with the pharmaceutical industry, and most of these relationships involve receiving food in the workplace (83 percent) or drug samples (78 percent), according to a study in the New England Journal of Medicine. More than one third of the respondents (35 percent) receive reimbursement for costs … Read more

By Peter Wehrwein New Orleans is called the Big Easy, but it’s not the kind of place where it’s easy to start an HMO. Everyone knows about the city’s great jazz, gastronomic delights and wild Mardi Gras celebrations. But the grim reality behind all the hoopla is that New Orleans is a poor city with … Read more

DAY BY DAY, PHYSICIAN STRIKES BECOME LESS ‘UNTHINKABLE’ The president of the Union of American Physicians and Dentists pulls no punches in describing the conflict between physicians and insurers. After launching the Union of American Physicians and Dentists in 1972, founder Sanford Marcus, M.D., met with George Meany, president of the AFL-CIO, seeking an affiliation. … Read more

Careful attention to a comprehensive treatment plan could forestall or prevent the need to add drugs and costs to a patient’s regimen Diabetes treatment largely has been a matter of waiting for failure: Eat healthily and exercise, and if blood glucose isn’t controlled, try drug therapy. If that doesn’t work, add a drug to the … Read more

Six Clinical trials were assessed. In 4 trials to preventing PONV, a larger proportion of patients that received amisulpride 5 milligrams compared to placebo experienced a total reaction. In two trials over treating PONV, a greater proportion of patients that received amisulpride 10 mg compared to placebo experienced a total reaction. Amisulpride Is beneficial for … Read more

Kentucky Gov. Paul Patton and a predecessor are squabbling over a decision to overhaul the health insurance plan that covers about 24,000 state workers. Patton is replacing Kentucky Kare, which allowed state workers to go to any physician, with a managed care plan built around networks of physicians and hospitals. In a letter faxed to … Read more

When Majority Leader Robert Dole of Kansas announced he would leave the Senate, Massachusetts Democrat Edward M. Kennedy accused him of leaving a “poison pill” behind by backing Republican demands that medical savings accounts be retained in the final version of the Kennedy-Kassebaum health insurance reform bill. MSAs, of course, are tax-free accounts that would … Read more

Formulary decision makers will probably be disposed favorably toward Xeljanz, the first Janus kinase inhibitor approved for rheumatoid arthritis Thomas Reinke In November, the FDA approved Xeljanz (tofacitinib) a novel nonbiologic medicine for rheumatoid arthritis (RA). It is the first Janus kinase (JAK) inhibitor for this disease. The Janus kinases are signaling pathways that affect … Read more

Health plan consolidation is giving the industry the mass it needs to do this year what was predicted last year, but didn’t happen: boost premiums substantially to prop up the bottom line.Hewitt Associates, the consulting firm, predicts nationwide premium hikes of 7 to 10 percent, up from last year’s average 3.7-percent increase. Glimpses of what’s … Read more

The company can be expected to be as tough in the PBM arena as in retail, but it has a few hurdles to overcome John Carroll Contributing Editor When Wal-Mart tackles a new market, it has enough brawn to bend prices for every player in the game. The retail leviathan’s low-price generic drug program — … Read more

David Brailer, MD, PhD, the nation’s health information chief, wants the industry, not the government, to devise a system that provides interoperability. David Brailer’s mission to speed the rapid proliferation of securely accessible electronic health records in the United States faces a big challenge over the next few months as he prioritizes the work that … Read more

We invited experts from around the country to weigh in on the strengths and weaknesses of Hospital at Home and what would be required for the concept to succeed in nonintegrated health care settings. These are responses to our cover story: Hospital at Home Saves 19% In Real-World Study Caring for the Whole Patient in the … Read more

More and more, mandatory arbitration clauses are surfacing in agreements between businesses and individuals. Will the line be drawn at managed care? In 1996, a radiologist reported that a CT scan of 6-year-old Zakary Ostertag’s head was “clear.” Two years later, after Zakary suffered a concussion, another scan showed a brain tumor. That tumor, it … Read more

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

As the November elections loom, the Affordable Care Act remains politically explosive. Nevertheless, 4 experts say, it’s time to start taking the next steps — toward a society whose policies truly help people keep their health. I once walked aimlessly for miles through fields full of land mines. Not on purpose, of course. It was … Read more

Studies by Cigna and Humana challenge some long-held assumptions about high-deductible plans When the University of Minnesota offered Steve Parente, PhD, the choice between a traditional health plan and a high-deductible plan linked to a health savings account, he went the HSA route. It wasn’t an easy choice. A family member has a chronic illness, … Read more

In large part, the growth of specialty pharmacy will require pharmacy benefit managers to become more active on behalf of payers and patients Warren K. Williams The advent of the Medicare Part D program in January 2006 along with other government initiatives has commoditized the traditional pharmacy benefit management (PBM) business model. Forcing transparency and … Read more

The new system is supposed to have transparent pricing, but some say it is susceptible to manipulation, which was AWP’s downfall A little more than a year ago, 45 states based their Medicaid drug payments on a common benchmark: an estimated acquisition cost based on the average wholesale price (AWP) of the therapeutic. And 37 … Read more

A sweeping change to the American health care industry, such as a wholesale move to a system based on defined contribution, is not favored by most people, according to a national survey that seems to reflect a conservative mood regarding medical coverage and a prescription drug benefit for the elderly. Today’s attitude reflects the change-it-slow … Read more

In addition to the 85 percent rule, the department is applying a ‘reasonableness’ criterion. But it’s all bark, no bite. John Carroll As 2010 was winding down, the Department of Health and Human Services took one final poke at the managed care industry. In carefully detailed language posted in the Federal Register, regulators took their … Read more

Insurers who recommend a particular provider or health care organization to a patient considering a surgical procedure need to determine how complex the procedure is and how frequently the surgeon performs the procedure. If the procedure is fairly common, like bypass graft surgery or coronary artery surgery, chances are good that a high-volume provider and … Read more

LOOKING FORWARD For other articles in the series, see listing at end Richard Hamer The two main players in the managed care industry have their work cut out for them for the next several years. While HMOs retrench, physicians need to become more constructive participants. The biggest wild card facing the industry in the next … Read more

MANAGED CARE March 2006. ©MediMedia USA Cigna hopes to marry convenience to cost effectiveness with a new benefit package that covers enrollees who get treatment for common ailments at MinuteClinic health care centers. “Effective Feb. 1, MinuteClinics will be part of our national provider network and services obtained by a member at a MinuteClinic will be a … Read more

After months of public criticism on the Purchase Price Increase of Epi-pens , CVS will stock a generic brand named Adrenaclick, still another kind of epinephrine autoinjector, for approximately one sixth of the purchase price. CVS will bill $109.99 for a two-pack in comparison to Mylan’s $600 epi-pen. But it ought to be said that … Read more

The estimated annual cost of treating patients with sepsis is approximately $20 billion in the United States, making sepsis the costliest medical condition in this country. Each year, an estimated 750,000 people die from sepsis in the U.S. But according to an article in the Journal of the American Medical Informatics Association, a hospital in Huntsville, … Read more

Costly protease inhibitors work well in many patients, but call for careful monitoring In less than a year, two new protease inhibitors — telaprevir (Incivek) and boceprevir (Victrelis) — have changed the standard of care for hepatitis C by introducing a new mechanism of action, but their significance goes beyond that. They are the first … Read more

Highmark’s effort to get physicians up to speed with 21st century technology has been extended with a bonus system based on federal standards John Carroll When Don Fischer, MD, contemplates the future of health care, he sees an electronic health record in the hands of almost every physician in the country. And Fischer, the chief … Read more

Precision Medicine in Primary Care: Bespoke. Genetic and Genomic. And Maybe Not Ready. With genomic sequencing on the rise and patients having more say about their treatment, two hot areas—predictive genetic testing and pharmacogenomics—promise to extend “personalized” medicine beyond cancer care. But will this precision improve outcomes and pay for itself? Say “precision medicine” and … Read more

Let’s be honest. Litigating lawyers love loopholes, and managed care has gigantic loopholes that are leading to big-dollar cases. The plaintiff’s bar worships Deep Throat’s advice: “Follow the money.” And because managed care emphasizes cost cutting and cost shifting, some lawyers seize on the economic incentives inherent in the system, finding ways to turn them … Read more

Color charts Also available in PDF The 10 largest hospital-owned HMOs, in terms of enrollment, grew by one third from 1996 to 1997. Chicago-based Rush Prudential HMO, whose enrollment nearly doubled, emerged as the largest. In fact, Rush’s enrollment by 1997 had more than quadrupled from the 78,000 it reported in 1995.

Treatment provides sustained pain relief through 48 weeks New data have supported the safety and tolerability of Belbuca (buprenorphine) buccal film (Endo Pharmaceuticals) for the long-term management of chronic pain in patients requiring around-the-clock opioids. The findings will be presented at the International Conference on Opioids (ICOO 2016) in Boston, which takes place on June … Read more

Last year, many women than men were registered at U.S. clinical schools. Yet over all ladies constitute just 34 percent of physicians from the U.S., along with sex parity remains not revealed in medical direction. Females account for Just 18 percent of hospital CEOs and also 16 percent of deans and department chairs at the … Read more

If 1% of patients account for 21% of total health care spending, why is there so little proof of ROI from giving them appropriate care? Think about this for a minute: Jeffrey Brenner, MD, says we have no idea how to deliver better care at lower cost. Brenner is the highly regarded executive director of … Read more

Contacts Vice President and Group Publisher Rate Card, 2015 Rate Card, 2014 BPA Statement Delivery Dates for 2015 for Managed Care Issue Space Commitment Run-of-Book Inserts January 12/10 12/22 12/29 February 1/9 1/22 1/30 March 2/10 2/23 2/27 April 3/10 3/16 3/20 May 4/10 4/22 4/28 June 5/11 5/22 5/29 July 6/10 6/22 6/30 August … Read more

Amgen Now announced positive Top Line results in the Phase 3 Analysis evaluating Repatha® In patients that have been receiving apheresis to cut back low density lipoprotein cholesteron. The study met its primary end point, demonstrating the treatment with Repatha somewhat reduced the demand for ldlc apheresis in mature patients, as measured in the ending … Read more

Once a sleepy system of indemnity insurers, the Blue Cross and Blue Shield network has awakened with the fervor of competition as its 63 plans strike deals with one another to gain muscle in the health care market.During May, three mergers made headlines. On May 3, Blue Cross of Northeastern Pennsylvania and Capital Blue Cross … Read more

Plans and PBMs are divided about sharing drug prices with clinicians. Is it better to have an administrative committee determine the formulary? When Edmund Pezalla, MD, MPH, joined Prescription Solutions as vice president and medical director three years ago, the company’s pharmacy and therapeutics committee evaluated the price the pharmacy benefit manager would pay for … Read more

ABSTRACT Purpose Colorado Access is a safety-net managed care organization that serves the medical and behavioral needs of the medically underserved. Because 75 percent of our population is children, we have had difficulty defining criteria to determine who is at risk for influenza and thus should receive an annual influenza vaccination. Our objective was to … Read more

Ingrezza and Austedo were approved last year. ICER calculations raise questions about their price. During my residency many years ago I rotated through a locked psychiatric ward, a place depicted in many movies and television shows but entirely new to me at the time. This was my first real glimpse at the people who were … Read more

Medical malfunction is considered the next victim into this healthcare providers. At the moment the healthcare errors become amazing challenges for healthcare professionals, and healthcare makers. All these are in charge of delay in healing of patients’ diseases, and at times impossible to regain. Even though it’s correct that deaths from medical errors would be … Read more

Though hospitals were the slow adopters of EHRs, most are now fully engaged in trying to satisfy the federal requirement for “meaningful use” of an EHR thanks to CMS financial incentives. Still, as much as acceptance of the complex requirements needed to earn incentives is now a given with three fourths of health systems achieving … Read more

MANAGED CARE May 2003. ©MediMedia USA Latinos are much more likely to report being uninsured than whites or blacks, according to a new study by the Kaiser Family Foundation. Seventy-three percent of Latinos who were surveyed are uninsured or know someone who is uninsured, compared to 63 percent for whites and 64 percent for blacks. Nearly 3,000 … Read more

CONFIDENTIALITY New techniques of verifying identity will allow sensitive information to be made available safely, conveniently, and expeditiously over the Internet. Karen Guenther Many people remember the great New Yorker cartoon from a few years ago in which a dog is seated in front of a computer, typing, as he thinks, “On the Internet, no … Read more

Advances in pharmaceutical technology are helping millions of Americans in ways never thought possible before, but development of new products is an expensive undertaking. A new study for the Blue Cross Blue Shield Association of America and the Health Insurance Association of America concludes that new drug development will help lead U.S. prescription drug expenditures … Read more

CDSS have been utilised to fortify clinicians inside their complex decisionmaking procedures. Considering their very first usage from the 1980s, CDSS have noticed a rapid development. They’re currently widely handled by electronic healthcare records along with different automatic clinical work flows, that has been eased by increasing worldwide adoption of electronic clinical records together with … Read more

At a glance Chicago Health Plan Value Project Sponsor organization: Chicago Business Group on Health Purpose: To make possible informed decisions on purchasing managed care Key conclusion: Health plan costs varied widely, and not necessarily with quality One research finding: 80 percent of employees had seen a primary care physician last year, but 16 percent reported “not completely … Read more

To outsource, or not to outsource? That is the question for Cigna, which recently hired the McKinsey consulting company to help determine whether the health plan should keep its information technology functions in-house. It’s all part of Cigna’s efforts to cut costs…. Aetna must pay $100 million as a result of a lawsuit filed by … Read more

Orphan Drugs: Way Too Many, Way Too Expensive Sales hit the billion-dollar mark as pharmaceutical companies have used the Orphan Drug Act to their advantage. Insurers are beginning to push back. Orphan Drug Debate: A Cheat Sheet No Price Pressure on Orphan Drugs (Yet) Projections show orphan drugs being a lucrative revenue stream for pharma … Read more

What goes around comes around. At least that’s what critics of the pharmaceutical industry seem to be saying as they gloat over reports that Novartis wants its employees to use more generic and over-the-counter medications. The brand-name drug maker also wants its workers to use mail order pharmacy more to “control the escalation of costs,” … Read more

The Striking Growth of antibiotic resistance makes Fresh Anti microbial procedures necessary. The researchers in Umeå University are analyzing an alternate strategy, to inhibit the disorder capacity of bacteria however, perhaps not their viability. Compared with conventional antibiotics, which regularly kill the germs, and the chance of resistance growth in adrenal bacteria is significantly lower, … Read more

The Medstat Group is developing a database intended to generate an elusive outcome metric: effect of illness on employee productivity. Medstat will crunch medical and pharmacy claims, absenteeism, and disability and workers’ compensation data to develop an indicator of cost and quality of care…. Mental health parity legislation is picking up speed in Washington. The … Read more

Managed care has another alternative to slow the progress of the most common cause of blindness in the 55-years and over population Thomas Morrow, MD Age-related macular degeneration (AMD) is the most common cause of blindness in people over age 55. AMD in all forms afflicts about 15 million in the United States. The disease … Read more

Complaint Rates On Indiana’s HMOs Available Online Indiana’s insurance department has posted information about consumer complaints against HMOs and other health insurers on the Internet. The number of complaints filed against each plan and resolved is provided, along with a “complaint index” that compares the plan’s percentage of all complaints to its market share in … Read more

Inprinciple, the body reflects a banned presence in character, preserved and shielded against breach that might endanger life. It’s in most religions as well as in artificial moral and ethical code of legislation. It allows dividing the human anatomy ethics in treatment and operation by permission, on condition that interference in the body is bound … Read more

California offers a prescription drug discount program that allows Medicare beneficiaries to get discounts just by showing their Medicare cards to pharmacists. Unfortunately, according to a new survey by the Kaiser Family Foundation, a majority of those eligible — both those with and without drug coverage — have never heard of the program. The findings … Read more

Business people have to come up with new products, and in our part of the economy, the hot product is consumer-directed health care. Yet we all know that a product that is sexy and well promoted and superficially attractive is not necessarily good for us all, individually or collectively. Take the Egg McMuffin or the … Read more

This study verifies, as defined by current guidelines, that initial treatment with fixed dose combinations (FDC) is associated with a better likelihood of HbA1c goal attainment and lower health care resource use and costs. Setareh A. Williams, PhD, director, economics and outcomes research, AstraZeneca LP; Erin K. Buysman, MS, associate director, and Erin M. Hulbert, … Read more

Introduction Editorial Advisory Board Instructions for Authors Papers already published: www.managedcaremag.com/research To supplement our coverage of the business of medicine, Managed Care publishes scientific peer-reviewed studies relating to the cost and effectiveness of programs, products, and procedures in health care financing and delivery. When Managed Care published its inaugural issue in 1992, we made a commitment to our readers to … Read more

Still, some are skeptical about punishing bad behavior. For one thing, it makes coverage more expensive for those who need it most. Lola Butcher Increasing employee deductible levels to encourage workers to be better health care consumers has become old hat. But how about this: tying an employee’s deductible level to health status? The idea … Read more

After modest beginnings, transdermal patches are now taking advantage of nanotechnology and other novel techniques to improve drug delivery. The simply designed transdermal patch has undergone a dramatic transformation over the past decade. In its strictest sense, all transdermal systems attempt to create a balance between a number of key factors including size of patch … Read more

It’s the nation’s leader in member satisfaction and quality of care, according to NCQA. Dynamic leadership and dominance of a region where excellent docs and plans abound are part of the formula. Frank Diamond Managing Editor Linkedin Share Button (link is external) Tweet Widget (link is external) Share on Facebook (link is external) About 25 … Read more

Health insurers’ aggressive stand on members’ use of generic drugs can attract new clients, but does it interfere with the physician-patient relationship? Martin Sipkoff Employers want their employees using generics — so much so that many employers are seeking out insurers offering pharmacy benefit designs that very aggressively push alternatives over brand names. They are … Read more

Since the Beginning of the Medicaid Managedcare Disagreement in Iowa,” Gov. Terry Branstad over repeatedly has pointed out to the reality that 39 states and the District of Columbia have transferred portions of the Medicaid populations in to managedcare plans. That is surely correct. More than 70% of those Country’s 7 3 million Medicaid beneficiaries … Read more

Introduction Recent regulatory pressures and certification requirements have heightened the need for payer organizations to abide by specific standards regarding medical management operations. Payer organizations that are making medical-necessity determinations regarding reimbursement for health care services, as well as risk-bearing provider groups to whom some of these functions have been delegated, must insure consistency and … Read more

Long in odds, the interests of individuals and providers are getting to be more harmonious and adapting. Both stakeholders will need to cooperate to take care of costs. Using generics and also biosimilars is 1 of the ways they are able to slowdown the slumping drug spend. All these drugs, which frequently carry prices at … 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 Martin Sipkoff 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 … Read more

Though claiming it never imposed gag rules on physicians, Aetna U.S. Healthcare has moved to rewrite its physician contracts to remove ambiguities that the AMA says effectively constituted “gags.” Aetna has sparred with physicians in several states over contract language, prompting numerous physician groups to leave the HMO. Earlier this year, Aetna and the AMA … Read more

Whenever a Canadian health system Changed from Regretting the Brandname anti-platelet medication Plavix into a far-cheaper frequent edition, Heartattack and torso pain patients proved no longer prone to die from some other cause or become re-hospitalized to get a center attack or unstable angina in just per year than people prescribed Plavix. Additionally, there were … Read more

The Health Insurance Portability and Accountability Act of 1996, originally the Kennedy-Kassebaum bill, dramatically increases the risks that all health care providers face when they fail to pay attention to reimbursement and self-referral rules. To ensure adherence to HIPA, every provider and managed care organization should create an internal compliance program, including mechanisms for investigating … Read more

Sometimes breaking old ground can be just as satisfying as breaking new. Take our cover story. The article looks at how the corporate cultures at Aetna U.S. Healthcare and Kaiser Permanente shaped their reactions to recent financial setbacks and positioned them for the future. What these two plans are looking at, experts believe, is a health care … Read more

Even as the economy sputters along, the work still must get done. Forty-eight percent of respondents to a recent Cejka Search and American Medical Group Association survey say their doctor group uses a retention program. Back in 2006, only 40 percent of physician groups had a retention program. The largest group likely to leave a … Read more

A Look Inside the World Of the Salaried Physician More and more doctors today are making the transition from independent practitioner to salaried employee. The switch is often painful, but they’re finding that their new status can bring a number of rewards. The 30-Minute Practice Checkup Is your practice ready to succeed under managed care? … Read more

Even the CEOs of all 70 among those most significant U.S. medical care businesses cumulatively have made £ 9.8 billion at the past few years as the reasonably priced treatment Act was handed, and also their earnings have increased faster compared to many people in america’ through this moment, based to a Axios investigation of … Read more

Hospital Mergers May Go on Whoever Wins in November Trump’s promise to repeal and replace the ACA could cut into revenues, but so could Clinton’s proposal for a public option. Readmission rates, bundled payments, ACOs — they fly under the radar of presidential politics and may continue regardless of the election results.   Robert Calandra … Read more

Medical Insurance companies Will Need to Devote their customers Estimated flat-rate prices for pharmaceutical medication and also reveal to the public that the negotiated prices they cover medication, under a sudden new Trump administration principle. It is the leaving Trump government’s most ambitious endeavor to Emphasize the complicated, confidential and lucrative system of pharmaceutical medication … Read more

HEALTH PLAN 2009 Leonard D. Schaeffer is the chairman and CEO of WellPoint Health Networks. WellPoint and another Blues plan, Anthem, are in the process of merging. With 26 million members, the new entity, to be called WellPoint, would be the largest insurer in the nation. Health care is projected to grow from 15 percent … Read more

Intensified efforts by managed care organizations to encourage members, pharmacists, and physicians to use generic drugs are slowly driving up the share of prescriptions filled with generics. The 46 percent of new prescriptions filled with generics in 1997 made up about 12 percent of retail prescription-drug sales. But for certain therapeutic categories, a majority of … Read more

Almost all workers with insurance have drug coverage, according to a report by the Kaiser Family Foundation. That’s 99 percent in HMOs and 100 percent in PPOs…. Pharmaceutical Research and Manufacturers of America launched a major educational campaign designed to block drug formulary plans in state programs, such as Medicaid. As a price of admission, … Read more

John A. Marcille Whether you take the story of the fall literally or consider it an interesting contribution to humankind’s reservoir of mythology, the lesson of the narrative cannot be easily dismissed. It is about how free will entered the world riding on a serpent’s tail. Remember that once the decision was made, the apple … Read more

Over the next three years, about 80 percent of drug spending will be driven by drugs in six broad therapeutic classes, according to the 2007 Drug Trend Report issued by Medco. The cardiovascular and central nervous system categories will account for almost half of the spending growth. Within these broad categories, nine specific drug classes … Read more

Payments to hospitals that adhere to “meaningful use” standards for implementing health information technology seem to be working. Medicare and Medicaid offer incentive payments to hospitals that use health IT under the American Recovery and Reinvestment Act of 2009, aka “the stimulus.” The percentage of U.S. hospitals adopting health IT rose from 16 percent to … Read more

Florida regulators last month ended a nearly 1.5 year-long effort to save Health Plans of America from its financial woes, and shut down the Maitland-based HMO. The plan was partly a victim of its success, at least in selling itself. The state blamed the plan’s collapse mainly on explosive enrollment growth, from 3,000 to more … Read more

Healthcare veteran Gregory Adams stepped into lead Kaiser Permanente Right as the Abrupt Passing of Bernard Tyson Adams’ interim standing became official one month after as soon as the country’s largest integrated health system’s board cemented his job as CEO earlier that past week. It’s one of several instances ever a Significant company has Made … Read more

As being a national court considers a struggle to the Affordable Care Act’s constitutionality, people, including many Republicans, wants protections for those who have pre existing requirements maintained, that the hottest Kaiser Family Foundation monitoring survey finds. Enormous Majorities of Americans also say it’s”very crucial” to maintain the ACA provisions which forbid insurers from denying … Read more

Membership growth in 2009 is expected to be modest, with growth in the low single-digit percentage range, according to the “2009 Managed Care Index Report” issued by the KPMG Healthcare & Pharmaceutical Institute. The one area that has seen growth in membership is the Medicaid managed care population, with states embracing managed care as a … Read more

Health plans are the pioneers of coordinated care, says Karen Ignagni, president and CEO of America’s Health Insurance Plans, and have led the way in health care through innovation. Therefore, they are not likely to go out of business; it’s more likely that they will continue to innovate, she says. “To say that health insurers … Read more

Business health coalitions expect health plans to continue delivering what employers want for their employees and dependents in 2007. And while it’s difficult to predict the future, there are four reasons for this bullishness, according to the National Business Coalition on Health (NBCH). The drive for quality improvement. NBCH collected data from 250 health plans … Read more

Whether an ACA fix or GOP plans—or neither—prevail, these players are poised to determine what comes next. On the day before Senate Majority Leader Mitch McConnell released his caucus’s first draft ACA replacement, Politico reported that Marilyn Tavenner, America’s Health Insurance Plans President and CEO, was among a coterie of AHIP officers holed up in his office … Read more

Download supplement Based on a breakfast symposium at the Academy of Managed Care Pharmacy 2007 Annual meeting, this supplement reviews opportunities to optimize short-term prevention of migraines in patients with specific treatment needs. The authors examine the advances in migraine prophylaxis and the emerging models in preventive treatment. Highlights Prevalence and Burden of Migraine and … Read more

Managed care organizations often place costly new drugs on a formulary’s priciest tier, but products for which substitutes do not exist often are made available at lower copayment levels. Average copayments for single-source, brand-name products are considerably lower than those for branded compounds available from multiple sources. Interpretation suggests that employers and MCOs recognize that … Read more

HMOs have reported HEDIS measures to the National Committee for Quality Assurance (NCQA) for more than a decade, and PPOs began reporting in 2005. NCQA says that the gap between HMO and PPO performance is narrowing. The findings are reported in The State of Health Care Quality 2009. HMO vs. PPO performance on select HEDIS … Read more

Unable to find an acceptable suitor for HIP Health Plan of New Jersey, state officials are liquidating the deeply indebted HMO they seized late last year. About 144,000 commercial subscribers have until the end of this month to find new coverage. Another 21,000 HIP Medicaid enrollees have been transferred to another HMO, which the state … Read more

Otilimab is really a monoclonal antibody, biologic medication, which aims and also inhibits the inflammatory cytokine GM CSF. At the Colleges of Oxford and Birmingham, and supervised by the Pharmaceutical company GSK, investigators researched the clinical ramifications of otilimab to avoid inflammation, tissue pain and injury in people who have RA. The analysis assessed the … Read more

Medication nonadherence costs billions. It costs almost $300 billion in avoidable medical spending — billions that payers can ill afford. It costs billions to pharmaceutical companies in lost business and it is now costing health care providers penalties, potentially in the billions, for not achieving accountable outcomes, such as hospital readmission rates, physician quality reporting … Read more

Company’s founder to face questioning at AACC meeting   Theranos founder Elizabeth Holmes is scheduled to present in-house data on August 1 at the annual conference of the American Association for Clinical Chemistry (AACC). This is the first time Theranos has agreed to share scientific information related to its controversial Edison blood-testing devices. An abstract … Read more

Clinical trial data from the lorcaserin submission suggest modest weight loss over a short period It is obvious to anyone walking in any public area of the United States that we have a major problem with obesity. Data from the National Health and Nutrition Examination Survey (NHANES) show that 36 percent of adults and 17 … Read more

If medical savings accounts were a stock, they’d be falling –if not plummeting. But if they were a stock, they just might be a good buy right now. According to a General Accounting Office survey, more than three-quarters of MSA vendors say that sales of qualified plans were lower than expected. But most experts expect … Read more

Minneapolis-based HealthPartners is rolling out the next phase of its Partners for Better Health Program, an outcomes-based initiative to promote quality improvement. New measures include outcomes standards for reduction of heart attacks, depression, and diabetes-related complications in its 660,000 members. HealthPartners says it will work with its providers and members to achieve, by 2005, 50-percent … Read more

The first lawsuit against an HMO under Texas’s health plan liability statute has been settled. The case involved a man who was discharged from a psychiatric hospital against the advice of his physician, then committed suicide hours later. The family sued what was then NYLCare 65, its medical director, and a behavioral health carve-out company … Read more

Current asthma Instructions Unite Follow-up, Treatment, and Clinical usage of biomarkers, such as fractional exhaled nitric oxide, together side normal management may offer clinicians with increased capacity to comprehend airway inflammation, streamline drug treatment, also potentially increase asthma control. Our purpose is to analyze the effect of FeNO tracking about the cost effectiveness of asthma … Read more

Download supplement STELARA® is a subcutaneously administered biologic approved by the US Food and Drug Administration in September 2009 for the treatment of adult patients (18 years or older) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. This Clinical Brief summarizes the 2 phase 3 multicenter, randomized, double-blind, placebo-controlled … Read more

Small businesses and individuals may soon be able to approach their state’s insurance exchanges, created through the ACA, and contract with private, not-for-profit organizations that sell health insurance products like HMOs or PPOs. Called CO-OPs (Consumer Oriented and Operated Plans), these organizations are made up of a board of members and are designed to offer … Read more

As 2011, CMS has established a decent MA provider network as fulfilling two criteria: the absolute minimum variety of providers and utmost travel time and space to all those providers. To signify local states, certain requirements are specific to different county types and also a selection of carrier types. Nevertheless, that the MA criteria tend … Read more

In the face of stiff competition from a growing category of dedicated wellness companies, major health plans are launching sophisticated, ambitious programs to slake employers’ thirst for these products America’s health plans have heard the message: Employers want wellness services, and the plans are delivering with gusto. The nation’s biggest plans are rolling out slick … Read more

In tying copayments closely to the actual cost of medications, Humana takes a step toward promoting awareness of resource use. 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 increases are … Read more

The EHC application attempts to align its own research topic array with the over all aims of the application, impartially and always employ predefined criteria to prospective issues, demand stakeholders to spot high-priority issues, be accountable and transparent, and always evaluate and improve procedures. A Topic prioritization group representing stakeholder and scientific viewpoints assesses subject … Read more

Resources Recent blog posts Disruptive Innovation Could Up-End an Innovative Industry Is There an Advocate in the House? Health Reform and the Use of Financial Incentives in Wellness Programs An Easy and Profitable Way to Turbocharge Disease Management? Welcome to the Redesigned Managed Care Magazine Website Blog on blogging more

NIH-funded team finds rapid-acting, nonaddicting agent in mouse study A metabolite created as the body breaks down ketamine likely holds the secret to its rapid antidepressant action, National Institutes of Health (NIH) scientists and grantees have discovered. This metabolite singularly reversed depression-like behaviors in mice without triggering any of the anesthetic, dissociative, or addictive side … Read more

John A. Marcille For all of its charts, numbers, and equations, economics often seems more art than science, better tracked by rain-dancers than prognosticators. It is so intertwined with the wiles and whims of human beings — be they suppliers or demanders — that the intangibles of psychology or free will keep throwing wrenches into … Read more

Deep Brain Stimulation Presents Radical Fix to Dire Opioid Crisis The last resort: Cut an inch-long incision into someone’s scalp. Then drill a hole into the skull that’s no bigger than a dime. Insert an electrode directly into the brain that targets the reward center, the nucleus accumbens. Then thread a wire beneath the skin … Read more

The researchers find that the costs of treating restless legs syndrome are fairly low, relative to the improved symptoms and associated health care outcomes, and are mainly attributable to prescription medication. Health plans are encouraged to expand coverage to reduce the associated suffering and costs. ABSTRACT Purpose: This study assessed the direct economic burden of … Read more

Hard-charging New York Attorney General Andrew Cuomo says reported rates are neither usual nor customary, nor are they reasonable For investigators in the New York attorney general’s office, the evidence seemed clear that UnitedHealth Group was running an insurance scam. They had a succinct example to demonstrate how it worked, too. Their research showed that … Read more

Increased Pressures Change P&T Committee Makeup Formulary committees once were stocked with academics and administrators. Today, primary care physicians, specialists, and retail pharmacists play a bigger role, and tomorrow’s membership will be even more diverse. The Coming HIPAA Crisis HIPAA’s timetable has been known for years, but many organizations that the law covers are dawdling … Read more

With more clothes frequently means we love them . We’ve got the complete cupboard, yet nothing more to utilize. Minimalists sign up to this thought that by owning , we free the time, energy, time and money to obtain the best out of everyday life. Since Marie Kondo will state, we have to just wear … Read more

To assess the clinical usefulness and analytical accuracy of fractional exhaled nitric acid within people age 5 decades and older having allergies; and also the capacity of FeNO quantified in the age 4 decades or more to predict a possible identification of asthma. We hunted from data bases’ beginning to April 20 17 for studies … Read more

At the height of the AIDS epidemic in the 1980s, someone who knowingly transmitted the virus to an unsuspecting partner would, in effect, be signing that partner’s death warrant, California officials at the time believed. Doing so could land someone in prison for six years. Times have changed and while such activity is still disparaged, … Read more

The Food and Drug Administration issued a draft guideline last month that would hold drug manufacturers liable for the activities of pharmacy benefit managers they own. The FDA wants PBMs to adhere to the same truth-in-advertising rules pharmaceutical companies must observe. The idea is to prevent PBMs from making misleading product claims. PBMs would have … Read more

Though this innovation focuses mainly on the provider’s role, only health plans have the assets, such as claims data, to make it succeed Health care industry pundits believe the Patient Protection and Affordable Care Act (PPACA) of 2010 will restructure the way millions of Americans receive health insurance, but that it may do little to … Read more

About 300 centers have antiviolence programs David Ross is a violence intervention specialist at the University of Maryland Medical Center. His team works with patients who are victims of violent injuries — stabbings, gunshots, or physical assaults — and who physicians flag as candidates for the program’s assistance. His challenge is to figure out the … Read more

They’re primed to work in teams, not fazed by large organizations, open to all kinds of measurement—and, of course, are tech savvy. But how well will this new generation of data-driven MDs deal with patients? There was good news for health plans and health systems at the inaugural conference for a new health law center … Read more

Although they’re not quite an endangered species, primary care physicians aren’t exactly in high demand these days, either. That’s been the experience of a national physician search and recruitment firm, Merritt, Hawkins, & Associates, during the past five years. The plight of family practitioners, general internists, and pediatricians is reflected by the average salaries offered … Read more

Despite a rise in the use of quality incentives to determine physician compensation, productivity remains the predominant determinant. “Despite the recent interest in pay for performance, quality-based physician compensation has been around for a long time,” says James Reschovsky, PhD, coauthor of “Physician Financial Incentives: Use of Quality Incentives Inches Up,” a report issued by … Read more

The recidivism rates for alcohol and drug addiction are heartbreaking, and efforts to help people crawl out of their private hells have mostly failed. It doesn’t look as if the patient-centered medical home (PCMH), one of the bulwarks of the Affordable Care Act, will help much either, according to a study in the Journal of … Read more

Medicaid plans in some states will expand, putting pressure on plans’ primary care networks Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD Before the Affordable Care Act was enacted, state Medicaid programs were required to provide coverage to certain categories of low income people, such as children, pregnant women, the disabled, and the elderly. Childless … Read more

Maternal age might be connected to predominance of consideration shortfall/hyperactivity issue (ADHD), as per another report. Though more established moms as a rule face more difficulties, the investigation uncovers that more youthful moms may really confront a higher danger of having a youngster who creates ADHD. The examination, distributed in Logical Reports, utilized the hereditary … Read more

Medications Improve or save lives, but Carried Wrongly or at excess They may cause patients worse. With tens of thousands of prescribed medication available on the current market, increasingly potent and popular overthecounter services and products along with a range of less-regulated supplements and herbs, usually no 1 prescriber or manufacturer knows that the entire … Read more

Or ESOs, because of fiscal incentive for employees. ESOs give employees the choice to purchase company stock at a future date at an amount established while the alternative is allowed. Employees usually do not cover his or her stock until they perform their choices. ESOs do perish, and also employees who leave the business normally … Read more

MANAGED CARE October 1998. ©1998 Stezzi Communications 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 … Read more

Only Medicare has the heft and reach to make cancer services more value-based, and recent reforms aim to do just that. Insurers keep close watch. For years now, national health plans such as UnitedHealthcare, Aetna, Cigna, and Anthem have been experimenting with clinical pathways, oncology medical homes, and episode payment arrangements to eliminate unnecessary variation … Read more

The study revealed that adding Praluent to existing therapy reduced LDL cholesterol by approximately 50 per cent in baseline (in comparison to two per cent growth in placebo). Praluent somewhat reduced the demand for apheresis treatment by 75 per cent in comparison to placebo (p less than 0.0001), the principal end point of this analysis. … Read more

Preferred provider organizations (PPOs) that are seeking National Committee for Quality Assurance (NCQA) accreditation will now be required to report clinical quality results through HEDIS. While nearly 150 million Americans are enrolled in a PPO, most of these plans do not collect and report quality data. In 2006, 80 PPOs submitted HEDIS data to NCQA. … Read more

An analysis of risk factors for hospital readmission following general surgery found that a large number of readmissions were not caused by suboptimal medical care or deterioration of medical conditions but by issues related to mental health, substance abuse, or homelessness, according to a study published online by JAMA Surgery. Previous studies investigating patients at risk … Read more

The search is on for ways to pay for health care that make value more important than volume. American health care is the most expensive health care in the world, gobbling up over 16% of GDP. It may also be the global leader in coining buzzwords and catchphrases. The current fav: value-based—as in value-based care, … Read more

Navigators, accredited program advisers, along with different assisters are tasked with the ACA with helping consumers know their insurance options and make informed conclusions concerning exactly what policy is ideal for them. Federal rules published annually based a selection of qualification, training, and run standards that assisters needs to meet. All these regulations demanded assisters … Read more

The pros and cons of each weigh heavily, but ultimately, a melding may benefit patients and primary care physicians According to the Disease Management Association of America, disease management “is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.” There are six components: Population … Read more

Two-way video communication has been a science fiction staple for generations. As this technology evolves from the incredible to the practical, telemedicine is proving useful for ensuring the quality of health care while reducing costs. But although sophisticated technology is within reach of the average person, managed care companies have been slow to embrace telemedicine’s … Read more

As the debate about how to fund a prescription drug benefit in Medicare heats up, a Commonwealth Fund study indicates just how much such coverage contributes to beneficiaries’ satisfaction. “Medicare beneficiaries who have prescription drug coverage were 50 percent more likely than those without it to rate their insurance as excellent and half as likely … Read more

Changing Payment Methodologies Force Physicians Into Larger Groups Health insurers will soon find themselves working with provider organizations that have vastly improved utilization management skills John Carroll Renewing Calls for Better Cost Profiling of Providers: A Conversation With Ateev Mehrotra, MD, MPH The information that many plans use needs to be open to physicians for review, … Read more

he switch to EDI’s 5010 data interchange standards requires full readiness — called level 1 by those in the know — in 21⁄2 years. Let the scrambling begin. John Carroll When the Obama administration moved into the corridors of power in Washington D.C., there was a brief period of uncertainty over new deadlines for the … Read more

Name Last modified Size Description Parent Directory 01-Mar-2005 11:31 – ../../../archives/0005/0005.weiner.pdf 01-May-2000 12:00 124k 0005.weiner.html 09-Apr-2003 23:32 45k 0005.washington.html 09-Apr-2003 23:32 8k 0005.states.html 09-Apr-2003 23:32 8k 0005.qna_eisenberg.html 09-Jun-2003 15:00 17k 0005.pity.html 09-Jun-2003 11:44 26k ../../../archives/0005/0005.outlook.pdf 01-May-2000 12:00 40k 0005.outlook.html 09-Apr-2003 23:33 2k ../../../archives/0005/0005.outlook.gif 01-May-2000 12:00 44k 0005.news_texas.html 09-Apr-2003 23:33 3k 0005.news_prescrip.html 09-Apr-2003 23:33 2k 0005.news_latest.html … Read more

A new rule by the Treasury Department is supposed to make flexible spending accounts more attractive, but stops short of creating the kinds of FSAs that experts have long said will attract millions of people. The Treasury Department has, in a sense, made the year 21Ž2 months longer for those who have FSAs. Enrollees get … Read more

Frank Diamond Managing Editor This new code set promises to delineate like never before the type of physician service rendered MANAGED CARE December 2008. ©MediMedia USA This new code set promises to delineate like never before the type of physician service rendered Frank Diamond Managing Editor Look to the blue horizon and behold the biggest systemic and … Read more

With physician recommended drug costs taking off and President Donald Trump vowing to make a move, an old thought is acquiring new footing: permitting Americans to purchase medications from unfamiliar drug stores at far lower costs. Another bill in Congress to permit the training would alter past wellbeing principles and eliminate a boundary that demonstrated … Read more

Can an injectable biologic really replace a delicate surgery for treatment of Dupuytren’s disease? Editor’s note: In health care, we deal in numbers so often that unless you are the treating physician, you sometimes cannot appreciate the quality of the personal experience that a successful or failed treatment might have. Here, an exceptionally articulate and knowledgeable … Read more

There are two transformations occurring in workplace based health promotion in America. The first is the movement from wellness to “well-being” and, related to this, a shift from a focus on a return on investment (ROI) to the use of value on investment (VOI) measures. These VOI measures are well documented and publicly available, but are … Read more

MANAGED CARE July 2008. ©MediMedia USA Spending on statins increased 156 percent between 2000 and 2005, according to “Trends in Statins Utilization and Expenditures for the U.S. Civilian Noninstitutionalized Population, 2000 and 2005,” issued by the Agency for Healthcare Research and Quality. In 2000, outpatient prescription expenditures for statins amounted to $7.7 billion. That rose to $19.7 … Read more

Insurers are trying different methods, from pay for performance to promoting preventive care, to hold down cost of chemotherapy drugs The cost of cancer drugs is skyrocketing, placing a significant burden on health plans. According to Morgan Stanley, cancer drugs accounted for 13 percent of drug expenditures in 2002. This year it will account for … Read more

MANAGED CARE July 2008. ©MediMedia USA Adding a third, more costly copayment tier for antidepressants reduces a member’s probability of using an antidepressant and also increases out-of-pocket spending by those who do use such a drug. This type of formulary design could be a problem for current users of antidepressants, says Dominic Hodgkin, PhD, associate professor at … Read more

DOCTORS TAKING BACK THE POWER? On the next several articles, MANAGED CARE describes four physician groups that have accepted full risk in order to win back control of medical decision making. We begin by exploring what such efforts mean for HMOs. Other articles in this series: Will Physicians Reclaim Control of Medical Care? [Introduction] They … Read more

With the advent of new disease-specific agents, some patients with HAE may find relief from its enormous physical and psychological toll Michael Toscani, PharmD Senior fellow, Jefferson School of Population Health, Philadelphia Marc Riedl, MD, MS Assistant professor of medicine and section head of clinical immunology and allergy, David Geffen School of Medicine, University of … Read more

While health plans have embraced alternative therapies, there’s little agreement on how to bill for them. The ability to demonstrate outcomes may help. Debra Gordon BRIDGING WORLDS When San Francisco lawyer Gerry Hinkley and his staff were helping a client form a PPO of complementary and alternative medicine (CAM) providers for a large California health … Read more

An Express Scripts analysis backs up industry claims that high-priced HIV medications may save money in the long run because they improve adherence. Sometimes, that pricey pill isn’t as expensive as you may think. That’s the takeaway from a recent analysis that found using expensive, single-tablet regimens to treat HIV is less costly than multi-tablet … Read more

We have a story in the works here at Managed Care on the mega–health insurers that may soon be roaming the land. Yes, the deals may yet run into antitrust problems, but the way things stand now there will be three super-sized national companies: an Aetna-Humana behemoth, an Anthem-Cigna giant, and the already gargantuan UnitedHealthcare. … Read more

There has been a gradual decline in employer-sponsored retiree health benefits for much of the last decade; notably, fewer retirees are offered coverage for prescription drugs. A new analysis suggests that a prescription drug benefit in Medicare would reduce employer expense for health coverage — which, in turn, could encourage more employers to offer some … Read more

Massachusetts can no longer require Medicare HMOs to provide unlimited prescription drug benefits. District Court Judge Richard Stearns decided that the federal law creating the Medicare+Choice program supersedes a state law barring prescription-benefit limits. The ruling pleased HMOs, which had been fighting for the right to reduce drug benefits, a move they said was needed … Read more

However new research finds that just 6 per cent of those patients have been carrying the medication as recommended by a physician. Thus, researchers attempt to find out: Should statins are so effective, why are a lot of people failing to accept them? The replies weren’t easy to find. The All of them received a … Read more

The Centers for Medicare and Medicaid Services (CMS) has been posting quarterly hospital quality star ratings based on patients’ experience of care on the Hospital Compare website since April 16, 2015. According to a July 21 announcement, the agency intends to release its most-recent star ratings for individual hospitals “shortly.” The star rating system takes 62 quality … Read more

At a glance Union Carbide Corp. Danbury, Conn. Goal: To improve drug compliance and realize savings for employees and employer Strategy: Emphasizes patient education Number of employees and retirees covered: 35,500 Number of covered individuals taking medications to lower cholesterol or to treat hypertension or diabetes: 9,000 Number of eligible individuals with compliance problems: 5,000 For as long as physicians … Read more

Harvard Pilgrim Health Care learned the hard way what Oxford Health Plan and others had already found out: HMOs need good information flow. The ink was hardly dry on Massachusetts’s new HMO insolvency law when its first case reared. An unexpected $60 million in additional 1999 losses, discovered early last month, convinced CEO Charles Baker … Read more

Health insurance premiums rose an average of 6.1 percent in 2007, less than the increase reported last year, but more than the increase in workers’ wages or the inflation rate, according to a report by the Kaiser Family Foundation and Health Research and Educational Trust. The increase this year was the slowest rate of premium … Read more

Don’t Bet That Problems With Part D Are Over Enrollment snags could be just the start of political and regulatory headaches facing health plans and pharmacy benefit managers Martin Sipkoff Pregnancy+Birth=$$$ With 9% of hospital charges attributable to pregnancy, delivery, and neonatal care, there is considerable opportunity for savings MargaretAnn Cross Consolidations Should Bring Nationwide … Read more

If you’ve ever grumbled about how the press plays up one tragedy while ignoring millions of successes, you won’t enjoy reading this. But you should. There’s a lesson here about managed care’s failure to tell its story effectively. At first I thought the bad buzz I was hearing about HMOs was no more than the … Read more

Submitted by Steven Peskin MD on Fri, 2012-09-21 11:05 As a baby boomer moving through middle age into the unspeakable age that follows “middle,” I was encouraged to read an article in the British Medical Journal that states that for seniors and super seniors, healthy behaviors that include regular exercise, not smoking, maintaining a normal Body … Read more

Insurers are being handed some treatment responsibility for this complex disorder, but some say that it is an educational, not medical, task   Advocacy organizations are making headway in state legislatures to expand mandated private health insurance coverage for autism services. In July, Louisiana and Pennsylvania passed legislation that guarantees specific services for children with … Read more

PDF version:  1301.peer_mnt.pdf ABSTRACT Objective: To evaluate the incremental cost of and health benefits attributable to medical nutrition therapy (MNT) for managed care members participating in an obesity-related health management program. Design: Retrospective case-control. Methodology: Overweight or obese adult managed care members who utilized the MNT benefit (n=291) were matched, using propensity score matching, with … Read more

Pay for performance so far has been only a stopgap measure to fix the fundamentally broken payment system, according to a report issued by PricewaterhouseCoopers’ Health Research Institute. The organization found that there is little quantifiable effect on health care quality, outcomes, and efficiency and there are insufficient financial incentives to change physician behavior. Findings … Read more

Abstract Asthma is a common chronic respiratory disease affecting nearly 8% of the U.S. population. It results in substantially higher direct and indirect costs as well as an increased mortality risk and poorer quality of life, particularly among patients with difficult-to-control asthma. While several physiologic tests, including spirometry, are typically used to diagnose and characterize … Read more

Some plans swear by the benefits of obtaining an “excellent.” Others say that customers care much more about cost. When the Quality Improvement Committee at Dean Health Plan in Madison, Wis., gets together, a recurring topic is whether to continue to pursue accreditation by the National Committee for Quality Assurance. The health plan earned full … Read more

Battle lines are drawn over proposals to raid the Medicare managed care program of funds to be applied to other health care needs. Democrats themselves are split. Pete Stark, chairman of the House Ways and Means Health Subcommittee, says he’s found $5 billion to help fund federal health programs. The only problem is that the … Read more

Last month, we advised physicians not to allow themselves to be decredentialed without putting up a fight. This month, we advise managed care organizations that, well, physicians are going to fight decredentialing — and as a result, MCOs should approach this process very carefully. There are many forces at work resulting in increased scrutiny of … Read more

Capitated payment for physician groups has had its critics lately, but a recent survey by a stop-loss insurance brokerage firm shows that its prevalence is still on the rise. Nearly 60 percent of physician groups now report receiving some compensation through capitation arrangements, and another 30 percent say they’ll be doing so within two years. … Read more

Second approval for once-daily EGFR-targeted therapy   The FDA has approved a supplemental new drug application (sNDA) for afatinib (Gilotrif, Boehringer Ingelheim) for the treatment of patients with advanced squamous cell carcinoma of the lung whose disease has progressed after treatment with platinum-based chemotherapy. Afatinib, an oral, once-daily epidermal growth factor receptor (EGFR)-directed therapy, is … Read more

Despite their attraction, these cost-control programs don’t always deliver The pressure on employers to manage the rising costs of health care is increasingly focused on the pharmacy benefit plan. Within the pharmacy benefit, there is a significant expenditure differential between specialty and traditional drugs. In 2012, traditional drug expenditure actually decreased by 1.5%, while specialty … Read more

Name Last modified Size Description Parent Directory 11-Jan-2005 13:10 – 0002.anticoag.html 20-Jun-2003 16:09 26k ../../../archives/0002/0002.anticoag.pdf 01-Feb-2000 12:00 65k 0002.candidates.html 20-Jun-2003 16:09 11k ../../../archives/0002/0002.compmon.gif 01-Feb-2000 12:00 37k 0002.compmon.html 09-Apr-2003 23:27 2k ../../../archives/0002/0002.compmon.pdf 01-Feb-2000 12:00 26k 0002.contents.html 09-Apr-2003 23:27 4k 0002.coop.html 20-Jun-2003 16:09 14k ../../../archives/0002/0002.cover.jpg 01-Feb-2000 12:00 12k 0002.editorsmemo.html 20-Jun-2003 16:09 3k 0002.harvard.html 20-Jun-2003 16:09 16k 0002.hospitals.html … Read more

Blue Cross and Blue Shield of Missouri has tentatively agreed to transfer its stake in its for-profit managed care subsidiary to a new not-for-profit health care foundation. The deal settles a two-year-old legal battle with Missouri Attorney General Jay Nixon about whether Blue Cross broke state law by transferring charitable assets to the subsidiary, RightChoice … Read more

Nearly 50 percent of members report that they don’t fully understand how to use their health insurance coverage and member services, according to the J.D. Power and Associates 2008 National Health Insurance Plan Study, which measured member satisfaction with 107 health plans in 17 regions through the United States. Members were surveyed on seven key … Read more

Whilst the OIG’s report clarifies, MA carriers receive Risk-adjustment payments, predicated inpart on investigations, to consider the diverse rates of their healthiness of their inheritance. This technique”levels the playing field to get [MA insurers] that enrol sicker beneficiaries that want more care.” Health practitioners and other providers initially submit payment asserts together with investigations into … Read more

Worried about implementing electronic health records? The Guide to Reducing Unintended Consequences of Electronic Health Records may be just what’s needed. Developed by Rand, it’s designed to help organizations anticipate, avoid, and address problems that can occur when implementing and using an electronic health record.… The number of underinsured adults — those with health insurance … Read more

A large Minnesota physician group and Medica have agreed to part ways at the end of the year, forcing more than 15,000 people to choose between their health plan and their physician. Family Health Services and Medica terminated their relationship after a dispute regarding patient autonomy. Family Health wanted to refer Medica patients only to … Read more

LOOKING FORWARD For other articles in the series, see listing at end Karen Ignagni For the first time, plans are in a position to work with physicians to improve outcomes, efficiency, and patient safety. Helping doctors would go a long way toward mending managed care’s image. At some point in the future, health plans will … Read more

I.T. and Greasy, Globby Doughnuts Submitted by Paul Terry on Wed, 2012-03-21 10:58 I love my colleagues in Information Technology. I also love greasy doughnuts. Why then, do I not love it when I.T. people bring in a big crate of greasy doughnuts to reward each other for their hard work? They only do this occasionally. Still, … Read more

Abstract Purpose: Electronic health records (EHRs), now used by hundreds of thousands of providers and encouraged by federal policy, have the potential to improve quality and decrease costs in health care. But interoperability, although techncially feasible among different EHR systems, is the weak link in their chain of logic. Interoperability is inhibited by poor understanding, by … Read more

Defensive medicine is something the public seems to be very aware of, according to a Wall Street Journal Online/Harris Interactive poll. More than half of adults in the United States say that they’ve declined treatment recommended by their physician because they felt it was unnecessary…. Pay-for-performance initiatives got a boost from the National Committee for … Read more

Experts who say that educating consumers will be the next method used to curb escalating health care costs often point to the success of tiered formularies, which have made patients more aware of the costs of medications. As the public’s understanding and acceptance of formularies might suggest, educating consumers and cost shifting are terms that … Read more

For the first time, the share of workers with employer-sponsored coverage who are enrolled in HMOs or point-of-service plans is falling, according to a William M. Mercer Inc. survey. Half of all covered employees in 1997 were enrolled in HMOs or POS plans, but that dropped to 47 percent last year. PPOs’ share, meanwhile, grew … Read more

January 2007 February 2007 March 2007 April 2007 May 2007 June 2007 July 2007 August 2007 September 2007 October 2007 November 2007 December 2007

Tougher standards being applied by insurers spur debate about what constitutes true value in a new drug Over the past six years, the Regence Group has employed pharmacists to sift through all the data they can find on newly approved therapies. They read the studies, both published and unpublished, mine the national databases, review FDA … Read more

These programs tend to operate on the fringes of cancer care, but a movement to make them more central gains favor Oncology pathway programs have demonstrated some ability to control costs, but these programs have not seen wide acceptance by physicians or health plans. Health plans have been cautious about tackling the required shift in … Read more

Inhalers Can Reduce Risk by 30% Vs. Beta Agonists A study by scientists at the University of British Columbia (UBC) shows that the steroid inhalers used by patients with chronic obstructive pulmonary disease (COPD) can also reduce their risk of lung cancer by up to 30%. The researchers examined data spanning a decade from 39,676 … Read more

The burden of diabetes just got bigger, according to epidemiologists at the National Institutes of Health and the Centers for Disease Control and Prevention. Nearly 13 percent of adults age 20 and older have diabetes, but 40 percent of them have not been diagnosed. An additional 30 percent of adults have pre-diabetes, a condition marked … Read more

An Institute of Medicine report sheds some light on race and medicine that all sectors of the health care system must pay attention to. The report — “In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce” — points out that the health care workforce does not mirror the rest of society’s move … Read more

By far the largest section of President Trump’s address to Congress last night focused on health care—15% according to a Wall Street Journal(link is external) analysis of the prepared remarks. Notably, the president vowed to “slash the restraints” that keep new treatments out of the hands of patients by doing away with the FDA’s “slow and burdensome” … Read more

Accountable care organizations and patient-centered medical homes are unlikely to succeed. Those are two predictions from Regina E. Herzlinger, a professor at the Harvard Business School who has successfully predicted some of the most powerful trends in health care since the 1990s. Arguably, most of her predictions about health care have come true or are … Read more

About 1 of every 14 Medicare enrollees is looking for new coverage this month. Call it fallout from Black Friday — Oct. 2, the deadline for health plans to decide whether to renew Medicare contracts with the Health Care Financing Administration. Citing unprofitable reimbursement, 43 HMOs and 22 other plans exited Medicare, while 52 HMOs … Read more

The quality of care delivered by health plans that publicly report their performance improved from last year, but gaps in quality remain and contribute from 42,000 to 79,000 avoidable deaths every year, according to a newly released study by the NCQA. The performance improvement recorded last year by the 563 health plans was among the … Read more

We’re now living in a universe of infinite choices and chances where fresh services are found at an flat-rate rate. At the era of invention , fresh solutions may be built in addition to current technologies faster than ever . Which usually means that there exists a fresh, even larger wave of invention before us … 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

A study confirms what has long been considered common but is rarely discussed: Physicians often lie about patients’ conditions to gain or improve coverage for their treatment. According to the Journal of the American Medical Association, 39 percent of doctors admit to upcoding, changing billing diagnoses, or reporting nonexistent symptoms. While the authors acknowledged these … Read more

Type Title Name Story A Multidimensional Framework For Specialty Drug Management webadmin Blog entry First Impressions Steven Peskin MD Story Specialty Pharmacy Management Will Become More Intense webadmin Story Don’t Get Caught By PBMs’ MAC Mousetraps webadmin Story Hammurabi’s Managed Health Care — Circa 1700 B.C. webadmin Story Patient Satisfaction: The Indispensable Outcome webadmin Story … Read more

Washington Watch Managed care legislation has replaced Medicare as the top health care legislative priority for both Congress and the White House, with presidential-election politics starting to enter the mix. The zeal to overhaul Medicare hit the skids after the Bipartisan Commission on Medicare Reform fell one vote short of making formal recommendations to Congress. … Read more

A review of the available research identifies payment for services in the absence of high-quality scientific evidence and presents an opportunity to use evidence-based medicine to develop a clinical coverage guideline Abstract Objective: To examine the medical evidence regarding the clinical efficacy and cost-effectiveness of the application of continuous subcutaneous metoclopramide and ondansetron to treat nausea … Read more

No longer does Mike Schoenleber, M.D., handwrite every prescription. Nearly all of the prescriptions that the Minneapolis-based family physician authorizes, he punches into his laptop computer and sends to the pharmacy. He relegated his prescription pad to the bottom of his office drawer a year-and-a-half ago. Forty-four-year-old Schoenleber works at a HealthPartners clinic with six … Read more

We’ve made strides in increasing the transparency of pricing in the pharmacy supply chain, and now we need to change dispensing behavior Pay for performance in medicine is a topic of wide discussion among managed care executives for its supposed ability to contain costs, to improve health outcomes, and to raise the overall quality of … Read more

The Lure of Tax Reform Politicians on both sides of the aisle are considering this as a way of fixing the system. What might it mean for health plans? Martin Sipkoff Just How Will CDHC Change Your Job? Medical directors are charged with many of the tasks that could help members make the most of … Read more

MANAGED CARE February 1998. ©1998 Stezzi Communications Washington Initiatives If medical savings accounts were a stock, they’d be falling –if not plummeting. But if they were a stock, they just might be a good buy right now. According to a General Accounting Office survey, more than three-quarters of MSA vendors say that sales of qualified plans were … Read more

David Pariser, MD Division of Dermatology, Eastern Virginia Medical School, Norfolk, Va. Carol Opper Clinical Research Scientist, Novartis Pharmaceuticals Corporation, East Hanover, N.J. Full text available in PDF ABSTRACT Purpose: To evaluate in-office dermatophyte test medium (DTM) culture as an alternative to traditional laboratory fungal culture for confirming a diagnosis of onychomycosis, and to determine the … Read more

John Carroll Contributing Editor Nobody doubts that the electronic medical record will promote better medicine, but at what cost? And to whom? Providers fear that they will bear the weight. For years, advocates of a comprehensive system of electronic medical records (EMRs) have had to settle for the moral high ground in the U.S., cheering … Read more

Ten percent of newborns are admitted to a neonatal intensive care unit. NICU costs are high but controllable.   Over the past 25 years, preterm births have increased more than 35 percent. Today, about one preterm infant is born every minute in the United States. The good news is that while preterm births are increasing, … Read more

Everyone involved seems to be grappling with ethical issues arising from the Human Genome Program. The science is still in flux. Although no one seems to know how to word them, there is general agreement among physicians, attorneys, legislators and managed care executives on one thing about the emerging science of genetic medicine: Development of … Read more

The evidence base is wobbly, but artificial intelligence is coming on strong and the hype for it is even stronger. Screening for diabetic retinopathy is an early application. Lingering questions include whether the use of AI will contribute to health care inequities rather than solve them. It seems like only several years ago, the health … Read more

Louis W. Sullivan, M.D.   Louis W. Sullivan, M.D.: “We must lose ourselves in selfless devotion to our communities, in fashioning answers to the challenges of improving health status.” Louis Sullivan, M.D., is president of Morehouse School of Medicine in Atlanta. An internist by training, he served as secretary of health and human services during the … Read more

Inexpensive wound dressings used to promote healing of venous leg ulcers have been shown to be just as effective as the more expensive antimicrobial silver dressings, according to a study published in the British Journal of Surgery. The study demonstrated that routinely using the inexpensive dressings could save the National Health Service of the United … 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. This paper has been peer-reviewed by appropriate members of Managed Care’s Editorial Advisory Board. This article also available in PDF Abstract Background Information: Percutaneous vertebroplasty is a therapeutic, interventional radiologic procedure … Read more

A survey of 200 pharmacies in Detroit and some surrounding suburbs finds that inner-city patients have a much tougher time obtaining painkillers. “The same drugs that reduce suffering of cancer patients are coveted by illicit [drug] users for their massive highs, making drug stores targets for break-ins,” reports the Detroit News, which conducted the survey. … Read more

Rationing, canceled treatments, and fearful patients A severe shortage of immune globulin is forcing doctors nationwide to cancel patients’ lifesaving infusions. Immune globulin helps protect patients from infections, and is used in many medical conditions, including seizures, leukemia, auto­immune diseases, organ transplants, acute muscle illnesses and nerve disorders.  “It is miraculous,” said John Boyle, president … Read more

MANAGED CARE June 2006. ©MediMedia USA Managed care always couched its emphasis on prevention with the caveat that diagnostic tests should be conducted according to generally accepted national practice guidelines. A new study seems to indicate just how costly preventive medicine can be when not tied to a disciplined approach. Unneeded medical tests directly cost the health … Read more

Associated chiefly with smoking smoking, smog or occupational exposure, which may lead to obstruction of airflow from the lungs leading to painful bouts of breathlessness. It affects around 329 million people worldwide and is now called to function as the next top cause of death by 20 30. Improving lung functioning and managing daily symptoms … Read more

Wal-Mart Announces Better Insurance Package For Part-Time Workers 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 … Read more

New Spin on Risk Assessment Demonstrated as Cost-Effective The authors argue that this method can enhance patient care by improving provider awareness, resulting in millions of dollars in savings. Alan H. Heaton, Pharm. D. ; Gina R. Westfall, Pharm. D. Preventive Care: Can We Do a Better Job? HMOs place great stock in disease prevention, but some … Read more

Battery-powered system delivers sumatriptan through the skin The FDA is investigating the risk of serious burns and potential permanent scarring with the use of the Zecuity (sumatriptan) iontophoretic transdermal patch (Teva Pharmaceuticals) for migraine headaches. Since marketing of the Zecuity patch began in September 2015, numerous patients have reported that they experienced burns or scars … Read more

Submitted by Steven Peskin MD on Sun, 2013-05-12 18:09 Alice found a Wonderland. What we found last week, when the Center for Medicare & Medicaid Services (CMS) released cost information for the 100 most common diagnoses and procedures in over 3,000  hospitals, is beyond Alice’s imagination. Some of the cost differences for the identical billing … Read more

Independent pharmacies in the Philadelphia area say they are being driven out of business by low reimbursements for Medicaid prescriptions, and have sued to force higher payments. All Medicaid patients in the Philadelphia area are in HealthChoices, a state-administered managed care organization that contracts with four HMOs to provide services. In suits filed in state … Read more

When some endocrinologists describe how diabetes can ravage the body, they use words like “ferment” and “pickle.” High levels of blood sugar, they say, act like the sugar added to pickle some kinds of vegetables–only the effect in the human body is devastating. High blood sugar causes blood vessels to decrease in size and eventually … Read more

President Bush has weighed in on liability, supporting a patients-rights proposal crafted in the Senate by Bill Frist, a Tennessee Republican, and Louisiana Democrat John Breaux. People would gain the right to sue HMOs in federal court for wrongful denial of coverage only after a case had been considered by an independent review panel. Pain-and-suffering … Read more

Right now large employers are obsessed with improving health and, not incidentally, productivity, says the chief analyst of a respected survey John Marcille MANAGED CARE August 2008. ©MediMedia USA Right now large employers are obsessed with improving health and, not incidentally, productivity, says the chief analyst of a respected survey Mercer has been tracking the insurance offerings … Read more

Highmark’s CMO seeks new and improved models of health care delivery John Marcille MANAGED CARE June 2012. ©MediMedia USA Highmark’s CMO seeks new and improved models of health care delivery John Marcille Health care reform gives insurers more incentive than ever to look for ways to help physicians improve quality and provide more efficient care, and Pittsburgh-based … Read more

Your typical American family of four is going to have $15,609 in medical expenses this year. That’s an increase of more than $1,100 from last year. That number is reported in the fourth annual Milliman Medical Index (MMI), which tracks the average yearly health care costs when the family of four is covered by an … Read more

Finally, Attention Switches To Progressive Multiple Sclerosis A surge of new MS treatments have been for the relapsing-remitting form of the disease. A new drug that targets CD20-positive B cells may change that.   Therapy for multiple sclerosis (MS) has been on a roll. Since 2009, a steady stream of more effective medications has been … Read more

In 1989the Institute of Medicine characterized Usage direction as a”pair of processes utilized by or for buyers of healthcare benefits to control health costs by affecting individual maintenance decision through casebycase assessment of the appropriateness of care before its supply ” 1 The definition remains true now but as time marches on, the significance of … Read more

For health plans and employer groups, the economics of battling obesity are not always obvious The economics of obesity have been murky for health plans and employer groups. On the one hand is the scale of what the Centers for Disease Control and Prevention considers a bona fide epidemic: About one third of U.S. adults … Read more

Many hospitals already have some variety of emergency diagnostic and treatment units. HMOs and physicians should welcome this level of care. EMERGENCY CARE Sooner or later, somebody with a sharp eye for the bottom line was going to notice: From the early ’70s until today, the average length of a patient’s stay in an emergency … Read more

Peer-Reviewed Is Executive Vice President and Chief Medical Officer of MediMedia, USA, which publishes Managed Care “You Can’t Outrun Your Past”…….. The title of a slide in a grand rounds presentation by Dr. David Kountz, senior VP for medical and academic affairs at Jersey Shore Medical Center and professor of medicine, UMDNJ-Robert Wood Johnson Medical … Read more

Despite pressure to cut state agency budgets, Georgia’s Medicaid program is expanding benefits and increasing payments to HMOs by 5 percent. Gov. Zell Miller has instructed all state agencies, including the Department of Medical Assistance, which oversees Medicaid, to trim spending by 5 percent for the fiscal 2000 budget that takes effect next July. Two … 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

A significant number of consultants, insurers, politicians, and, oh yes, the companies that purchase health care are increasing their interest. Chris Hakim was one of the first to get out into the market with a high-deductible insurance plan linked to a health savings account. In early 2004 he helped roll out Aetna’s small-business HSA plan … Read more

More than 5,150 cases reported in U.S. since 2015 Fewer than one in 10 Americans believe it is likely that they will be infected by the Zika virus, according to a recent Gallup poll. The results of the survey reveal Americans’ low levels of concern about Zika despite widespread reports of how the virus affects … Read more

Narrowing the coverage gap will help beneficiaries, health plans, and even pharmaceutical companies. Just how to do that is debatable. Martin Sipkoff Nobody seems to like the doughnut hole — not seniors, not health care reformers, not even the drug companies. “The drug companies have made a handshake deal with the Obama administration to provide … 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

When the approach in one town is major surgery and in another, it’s watchful waiting, you know there’s a problem. Unwarranted variation in medical practice is costly — and deadly. Analysis of Medicare data reveals that per-capita spending per enrollee in Miami is almost 2.5× as great as in Minneapolis, even after adjusting data for … Read more

Republican efforts to repeal and replace (or even fine tune) Obamacare keep running into a seemingly insurmountable object; the desire among many Americans to maintain at least some parts of the ACA, according to STAT. Allowing grown children to stay on their parents’ health plan is one that’s gotten a lot attention. Now, four Republican senators … Read more

Drug Cost-Sharing Amounts Stable 2010 to 2011 From Managed Care Managed Pharmacy Drugs pharmaceuticals Read more

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Many states, helped by a few health plans, are striving to develop health information exchanges, encouraged by federal stimulus funds Health information technology (HIT) offers great promise for improving the quality of care, including reducing medical errors and lowering administrative costs. But that promise will be fulfilled only when health systems, doctors, pharmacists, and health … Read more

Not Because the HIV/AIDS Outbreak Gets Got the United States of America faced as Devastating and fatal that a health condition as the present catastrophe of esophageal abuse and esophageal and esophageal use disease. Current domestic trends indicate that every year more people die of overdoses–that the vast majority that involve antipsychotic medication –compared to … Read more

From the USA from 2001-2002 into 2012 2013, primarily based on research by the National Institute on Alcohol Abuse and Alcoholism,  a part of the National Institutes of Public Health. Almost 10 million Americans, or 4.1 per cent of their mature populace, used antipsychotic drugs in 2012 2013 that a category of drugs which features … Read more

Seeking the best return on shared-savings programs such as PCMHs and ACOs, health plans are investing cash and other resources to attract and hold patients’ attention Joseph Burns Contributing Editor Have health insurers taken a lesson from Yogi Berra? In a television commercial, the former Yankees catcher and manager outlines a certain insurer’s strategy, saying, … Read more

The impact of this debilitating disease has been largely underestimated, yet new biologic agents offer significant clinical benefit to those afflicted. Full text available in PDF INTRODUCTION Plaque psoriasis, also referred to as psoriasis vulgaris, afflicts upwards of seven million Americans (Koo 1996). Because psoriasis is a cutaneous disorder, many have underestimated its medical impact … Read more

Accountable care organizations and patient-centered medical homes are unlikely to succeed. Those are two predictions from Regina E. Herzlinger, a professor at the Harvard Business School who has successfully predicted some of the most powerful trends in health care since the 1990s. Arguably, most of her predictions about health care have come true or are … Read more

HEALTH PLAN 2009 Kenneth S. Abramowitz is a senior adviser at the Carlyle Group, an investment company based in New York, and has served as managing director on Carlyle’s Healthcare Team. Much of today’s discussion about employers getting out of the health care business focuses on contributions to workers for direct purchase of health care … Read more

If You Think It’s Bad Now, Plans Could See Worse Dwindling market share, rising costs, and a drastic drop in investment income buffet the health insurance industry A Conversation With Stephen C. Schoenbaum, MD, MPH: Learn From Existing Examples of Excellence Great work is being done in many places, says an executive of the Commonwealth … Read more

The recent 40th anniversary of the surgeon general’s report on smoking brought some staggering statistics to the public’s attention. The New England Journal of Medicine reports that “In 2001, the prevalence of smoking in the United States stood at 25.5 percent among men and 21.5 percent among women, down from the peaks of 57 percent … Read more

Which plan designs and strategies do employers feel are the best at reducing pharmacy costs? Respondents to a survey sponsored by the Pharmacy Benefit Management Institute (PBMI) identified potential strategies from “eliminating fraud, waste, and abuse” to “increasing member cost share.” Of the five strategies suggested, employers felt that “aggressive formulary management” would be most … Read more

MANAGED CARE December 2000. ©2000 MediMedia USA Almost 40 states have laws giving health plan members the right to seek external review of denials of coverage. Conflicting federal court rulings about states’ authority to bind health plans to external review decisions have put their constitutionality in question. The U.S. Court of Appeals for the Fifth Circuit last … Read more

Dark-suited gentlemen stride purposefully into your reception area and ask to see the person in charge. The visitors announce that they are with the federal government — the U.S. Attorney’s Office, or the FBI, or the Office of Inspector General — and that they have a warrant to seize documents and other materials. What do … Read more

“GramNegative Compounds are among the very most Intense antibiotic immunity dangers and induce significantly more than 40,000 resistant diseases from the U.S. alone annually,” David Nicholson, PhD,” main R&D officer of Allergan, said in the discharge. “This brand new [supplemental New Drug application (sNDA)] endorsement for Avycaz is according to a significant clinical trials, containing … Read more

The complications of autograft surgery are largely avoided when advances in biotechnology play a role in tissue regeneration and repair Thomas Morrow, MD Nearly 850,000 bone grafts are performed in the United States each year for reasons as varied as severe spinal disease, foot and ankle fusions, nonhealing long bone fractures, and joint replacement revision. … Read more

CAHPS Identifies a Category of standardized Polls That May Be Accustomed to Assemble and record information about customers’ experiences with health providers and plans. The CAHPS Health Plan Study Is Composed of More than Forty things which inquire that the Respondent to speed their own adventures with various characteristics of maintenance, for example entry, timeliness, … Read more

A mix of 2 drugs maintains patients who have chronic lymphocytic leukemia and living longer compared to the present standard of maintenance, as reported by a phase3 clinical trial of over 500 participants ran at the Stanford University School of Medicine along with multiple different associations. The outcome of the trial are more most likely … Read more

Prescription drug spending in the United States has been tempered in recent years by patent expirations and corresponding patient conversions to generic drugs. Rapid growth in spending on biologics, however, threatens to send pharmacy budgets soaring. A new report by Evaluate Pharma indicates that by 2018, biologics will account for one quarter of all drug … Read more

Using case studies, researchers assess the effect of rebate rates on the cost-effectiveness of two oral bisphosphonates that are competing for tier 2 positioning ABSTRACT Purpose: Because of rising drug expenditures, cost considerations have become essential, necessitating the requirement for cost-effectiveness analyses for managed care organizations (MCOs). The study objective is to examine the impact of … Read more

Insurers are largely happy with what they’ve seen. They’re creating new benefit packages and expect more business in the next one to three years. Since the beginning of this year, XLHealth has been carefully testing a new market in Baltimore and seven Maryland counties. Spreading the word through local doctors and nurses, the disease management … Read more

Sounds like capitation to me. Blue Cross & Blue Shield of Massachusetts is proposing to overhaul the way it pays doctors and hospitals. The plan wants to stop paying doctors and hospitals for each patient visit or treatment, and instead wants to pay a flat sum per patient each year. The fee would be adjusted … Read more

Express Scripts’ program manages biologics dispensed under the pharmacy and the medical benefit Frank Diamond Managing Editor 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, … Read more

In Spite of the Fact that That the Zika virus has infected millions of people–for Example a Large Number of Expectant Mothers Close and Worldwide to 300 Expectant Mothers in the USA –Senate Has to pass a bill which could provide financing to combat it. On Tuesday, Senate yet more neglected to pass on a … 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

Are new physicians learning everything they should about how pieces of the health care system should work together? No. Is progress being made? Yes. Bob Carlson Contributing Editor David Stevens, MD, sat down and tried to think about what has changed in health care in the last decade. “We saw genomics coming, but we still … Read more

  The first study to examine the effectiveness of telemedicine consultations for newborn resuscitation demonstrates the technology’s strengths and weaknesses, according to Mayo Clinic researchers. One of the strengths is that telemedicine consultations can improve the quality of care in local hospitals, possibly reducing the necessity of transfers to hospitals with higher levels of care, … Read more

Now the U.S. Food and Drug Administration approved Adakveoa treatment to decrease the frequency of vasoocclusive catastrophe — a more typical and debilitating complication of sickle cell disorder which develops when the circulation of blood is blocked by sickled red blood cells — like patients age 16 decades and older. “Hope never been high for … Read more

A committee at the Institute of Medicine has called for better use of registered nurses, but physicians continue to try to keep them subordinate The simmering controversy over whether advanced-practice nurses should be deemed full-fledged primary care providers seems to be coming to a boil. There are many physician-oriented mandates in state laws and federal … Read more

A longtime consultant says health plan CMOs now have the toughest job in managed care In all of the talk about the Affordable Care Act, what’s missing from the debate is the recognition of how the roles of clinical executives at health plans are changing — and how critical they will be to accomplishing the … Read more

You don’t really have a true pay-for-performance program if it doesn’t say so on the bottom line David A. Sparrow The vast majority of entities that have implemented pay-for-performance initiatives have chosen to focus almost exclusively on improving the quality of care rather than on reducing its cost. While it is obviously important to address … Read more

MANAGED CARE December 2011. ©MediMedia USA Higher out-of-pocket costs reduce utilization, according to a report by PricewaterhouseCoopers. The report (http://pwc.to/vYdbaE), based on a survey of 1,000 people, collected consumers’ perspectives on what sort of health care services they prefer and what they think of the changing health care landscape. “Higher deductibles and co-pays have suppressed utilization,” the … Read more

Seeking the best return on shared-savings programs such as PCMHs and ACOs, health plans are investing cash and other resources to attract and hold patients’ attention Have health insurers taken a lesson from Yogi Berra? In a television commercial, the former Yankees catcher and manager outlines a certain insurer’s strategy, saying, “And they give you … Read more

Introduction and purpose: Age-related macular degeneration can be a significant cause of blindness in many highly developed states, with blindness regularity of 8.7 percent. This guide is a summary of the most recent therapeutic choices for AMD.A brief description of this condition of comprehension: AMD can be just a multifactorial disorder which etiology isn’t completely … Read more

Also available in PDF ABSTRACT: Diffusion of Innovations and Opinion Leader theories can be translated into practical applications to improve health care delivery and financial performance by applying them to influence referral patterns and decrease variations in care. Health care organizations can rapidly spread “better practices” to their practicing physicians by understanding the social and communication … Read more

Some call it concierge care for the masses. Born out of physician frustration with insurers, ‘DPC’ could become more popular if Congress passes legislation that allows people to use HSA funds to pay the monthly fee. Direct primary care, sometimes described as concierge care for the masses, is still a relative newcomer to the health … Read more

Just a week before the National Committee for Quality Assurance released 1997 HEDIS data, a Commonwealth Fund study burst the buildup over the HEDIS release like a badly worn tire.According to the authors, only 6 percent of employers of 200 or more workers use HEDIS (Health Plan Employer Data and Information Set) information to select … Read more

Insurers must spend at least 80 to 85 percent of premiums on direct care for patients, as well as on efforts to improve quality of care, according to new regulations from the Department of Health and Human Services (HHS). The regulation, the medical loss ratio (MLR) provision of the Patient Protection and Affordable Care Act, … Read more

Geisinger’s “warranty” for CABG surgery has gotten a lot of attention, but is it transplantable? Somewhere along the line the word “warranty” was used to describe ProvenCare, Geisinger Health System’s experimental program for coronary artery bypass graft (CABG) surgery. It stuck. Geisinger is a health care company in central and northeastern Pennsylvania with about 2.6 … Read more

All-products provisions in health plan provider contracts are slowly being negotiated, legislated, and regulated out of existence. They are now illegal in at least four states; legislation is pending in several others. Non-negotiable all-products requirements leave physicians with an all-or-nothing choice: Either agree to be on the provider panels for all current and future products … Read more

Physicians, teachers, and clergy are among those professions that enjoy particular respect. They must preserve equanimity in the face of ephemeral social movements. War protests and freedom of speech. Remembrance of times past. The U.S. has embarked on another foreign military adventure. It’s worth reviewing some of the polarizing effects of war on civilian professionals. … Read more

One doctor demands $39,000 for a child’s surgery; another bills $56,890 for a bedside consultation In March, newspapers in New Jersey reported that Aetna was suing several New Jersey physicians over medical bills for out-of-network care, bills Aetna said were unconscionable. One doctor billed $56,890 for a bedside consultation; another billed $59,490 for an ultrasound, … Read more

Combination product consists of Tresiba and Victoza The FDA has published a briefing document ahead of the May 24 meeting of its Endocrinologic and Metabolic Drugs Advisory Committee to discuss the new drug application (NDA) for IDegLira (Novo Nordisk), a fixed-dose combination of insulin degludec (Tresiba) and liraglutide (Victoza). The product’s proposed indication is as … Read more

For the more than 560,000 Physicians and health care students represented with the joint memberships of those above mentioned businesses, we’ve adopted these principles to tackle the opioid tragedy impacting a substantial number of families, individuals, and communities throughout the nation. The catastrophe has left few untouched, and using a mean of 11-5 Americans dying … Read more

Pediatric heart transplant has Been the standard of Maintenance for Endstage Heart disorder in kids across the environment. The amount of transplant has increased significantly as the transplant was conducted, along with throughout the previous 2 decades, results have continuously improved with progress in consciousness enriching the clinical course and consequences of the patients. Shortterm … Read more

The problem with managed care is insurance, says Georganne Chapin, president and CEO of Hudson Health Plan in Tarrytown, N.Y. Her solution to one of the most difficult problems health insurers face involves removing the risk-financing mechanism. Adopting a single-payer health care system would allow plans to do what they do best: deliver patient care, … Read more

Recommended daily managed care news links: Kaiser Foundation Daily Health Policy Report http://www.kaisernetwork.org/daily_reports/rep_hpolicy.cfm Healthleaders http://www.healthleaders.com/news/section.php?categoryid=10 American Healthline from Robert Wood Johnson Foundation http://www.rwjf.org/newsEvents/ahlNews.jhtml AAHP Smart Brief Free daily email, enroll at: http://www.smartbrief.com/aahp/ KPMG Insiders Free daily email, enroll at: http://www.kpmginsiders.com/login.asp Yahoo Healthcare Industry Center http://biz.yahoo.com/ic/he.html Modern Healthcare Daily Dose http://www.modernhealthcare.com Wall Street Journal Online Health … Read more

Health plans are taking profitable cues from national retailers and providing members with coupons for newly available over-the-counter products. Blue Care Network (BCN) of Michigan is taking its cue from the retail ranks of CVS, Rite Aid, ShopRite, and Target by providing coupon savings to its allergy sufferers. It is a growing trend among other … Read more

An MCO with an integrated medical and pharmacy benefit management system can overcome the challenges associated with this costly category Gregory K. Bell, PhD Shannon A. Baumann, MS Growing challenge of specialty drugs There is no standard industry definition of specialty drugs, although many characterize these products as simply high-cost pharmaceutical therapies. For example, the … Read more

HMOs have reported HEDIS measures to the National Committee for Quality Assurance (NCQA) for more than a decade, and PPOs began reporting in 2005. NCQA says that the gap between HMO and PPO performance is narrowing. The findings are reported in The State of Health Care Quality 2009. HMO vs. PPO performance on select HEDIS … Read more

Most would not want health care to go through such a major change unless it became a question of survival. Many say that’s just where we are. For 30 years, Judy Spelman had a front-row seat on the daily drama of hospital life — much of that time working as an emergency room nurse. But … Read more

“We can’t continue to put every drug willy-nilly on every formulary,” says David B. Nash, MD, MBA, the founding dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia. Some organization will need to start monitoring this, but he hopes it won’t be another federal agency. Watch the full interview with Dr. … Read more

President Donald Trump has considered lowering the Elevated cost of Prescription medication to be just one of the trademark problems, and it’s very likely to become a talking point he is based on all through the upcoming effort. Throughout his day address Monday — delivered to the very first evening of That the Repubublican National … Read more

Seeking the best return on shared-savings programs such as PCMHs and ACOs, health plans are investing cash and other resources to attract and hold patients’ attention Have health insurers taken a lesson from Yogi Berra? In a television commercial, the former Yankees catcher and manager outlines a certain insurer’s strategy, saying, “And they give you … Read more

It seems many of us have some preconceived ideas of what new Medicaid members will look like: They’ll be older, sicker, higher utilizers of services and, more challenging to care for. But when we take a closer look at populations that will qualify for Medicaid over the next several years, a different picture appears. Chances … Read more

Three health care issues have become important in the presidential campaign, but few people understand the major parties’ positions on those issues — and fewer still have any stomach for real change. A Merrill Lynch analysis suggests that even as Americans tell pollsters they want something done about Medicare, the Patients Bill of Rights, 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 prevalence of moderate to acute COVID-19 found in the usa and reported at additional COVID-19 vaccine studies is considerably more than supposed during routine planning. More over, dependent on such an prevalence and modeling, there’s a high level of probability that a efficiency signal fulfilling the prespecified criteria within this change is going to … Read more

Being a Medication salesman, Mike Courtney worked Tirelessly to Earn Medical Care High priced. He also wined and dined medical practioners, golfed using these bought lunch to get his or her entire Builders — all to market tablet computers regularly costing tens of thousands dollars every calendar yr. He’s really about an alternative assignment. If … Read more

Health insurers will soon find themselves working with provider organizations that have vastly improved utilization management skills At the beginning of this year, Advocate Health Care, a not-for-profit integrated provider network with 10 hospitals and 800 employed physicians in the Chicago area, inked an accountable care organization (ACO) network deal with Blue Cross & Blue … Read more

  Oral/Infusion Cancer Drug Parity Begins to Raise Health Plan Costs MANAGED CARE January 2012. © MediMedia USA LEGISLATION & REGULATION Oral/Infusion Cancer Drug Parity Begins to Raise Health Plan Costs Legislatures want medical-benefit practices applied to oral drugs provided under the pharmacy benefit, all to keep patients’ costs within reach John Carroll A little more … Read more

Delafloxacin is a oral or intravenous antibiotic Suggested for Its Treatment of severe bacterial skin and skin structure infections, including both the grampositive (including methicillin resistant Staphylococcus aureus along with GramNegative organisms. Chemically distinct from several other quinolones, delafloxacin shows improved effectiveness, specially contrary to grampositive pathogens. The integration of efficiency data throughout the Stage … Read more

Employers want cessation efforts, and not-for-profit plans, as well as a few for-profits, have come through Almost everyone agrees that tobacco use is the single most preventable cause of death in the United States and a key factor in America’s $1 trillion annual bill for chronic care. Yet until recently, the major payers for health … Read more

Providers and payers Are Still chip away in the years of Builtup Sifting through fresh ventures aimed at reducing health costs, improving maintenance and maybe above all, sharing data. Make no mistake; that often-fraught dating hasn’t caused it to be on the hump entirely. More importantly, but both sides are revealing indications of final that … Read more

Providers should enter into managed care arrangements with the intent that they be long-term relationships. Even when the contract term is short (for example, one year, renewable), the contract is only worth the effort to negotiate if the relationship will probably survive for a while. Would you seek out a romantic relationship with someone who … Read more

PCSK9 inhibitor lowers low-density lipoprotein-cholesterol levels The FDA has approved the supplemental biologics license application for a once-monthly (every four weeks) 300-mg dose of alirocumab injection (Praluent, Sanofi/Regeneron) for the treatment of adults with high low-density lipoprotein-cholesterol (LDL-C). Alirocumab is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of … Read more

Ever since that time, further randomised clinical trials of both HAP and VAP are ran along with fresh information is now available. Studies of epidemiology, identification, empiric therapy, response to treatment, fresh antibiotics or fresh kinds of antibiotic management and illness avoidance have shifted older paradigms. Additionally, essential differences between procedures from Europe and the … Read more

In late July, when Pillowtex, a textile manufacturer in North Carolina, declared bankruptcy, 7,650 workers lost their jobs. Health benefits became an immediate concern — no surprise there. Blue Cross and Blue Shield of North Carolina took up some of the slack, offering displaced workers guaranteed health insurance coverage in which the federal government will … Read more

The National Committee for Quality Assurance says it will begin an accreditation program for medical groups two years from now. Still in development, the program would provide third-party judgment of physicians across plans. Many plans now issue their own report cards on physician group performance. Given that HMOs’ and NCQA’s underlying reasons for wanting to … Read more

The accompanying area presents the bit by bit procedure used to build Target Costs for both ACH and PGP Members. Area 4.1 portrays the danger agents used to appraise recipient and companion changed Clinical Scene level spending. Segment 4.2 talks about utilizing the danger change model used to gauge Clinical Scene spending. At last, Area … Read more

Kaiser Permanente and the federal Agency for Health Care Policy and Research are cooperating on a project designed to help physicians identify patients in primary care who could benefit from behavioral health services. The goal is to enable health plans to offer proactive interventions to appropriate individuals through primary care. Researchers want to gain a … Read more

Clinical Decision Support On Slow Road to Adoption These systems can improve quality, but in their present state of development, they can annoy physicians and are underutilized Tom Reinke Mrs. Jones, a 64 year old with diabetes, goes to her physician’s office for an upper respiratory infection. She has not been there for a few … Read more

Although widely used in health care, pay-for-performance (P4P) incentives have resulted in only modest improvements, says a new study. Rand Corp. explores seven design features that could improve P4P programs — features that primarily rely on changing physician behavior. “Pay-for-performance programs are designed in a number of ways. One of the common designs provides physicians … Read more

FDA rejects software modifications Alere Inc. has initiated a voluntary withdrawal of the Alere INRatio and INRatio2 PT/INR anticoagulation monitoring systems from the U.S. market. The devices determine the international normalized ratio (INR) in samples of capillary whole blood. Alere is working with the FDA to determine the most appropriate timing for product discontinuation and … Read more

An-out-of-network care provider is somebody who has not consented to engage with your own insurance or accept that the negotiated rates that your insurance policy pays for a specific medical support. Based upon your insurance program, you could not have any policy for out-of-network maintenance, or you can need to cover increased co insurance expenses … Read more

Coverage often straddles the line between the pharmacy and medical benefit, but a properly constructed formulary can bridge the gap F. Randy Vogenberg, RPh, PhD Specialty drugs and other new drug technologies are the fastest growing sector of the prescription drug market primarily because of price inflation and increased utilization. Manufacturers have justified the high … 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

  2017 Media Kit 2017 Editorial Calendar 2016 Ratecard and Production Specs BPA Statement Issue Space Commitment Ad Materials Inserts January 12/1 12/8 12/16 February 1/3 1/8 1/13 March 2/1 2/3 2/7 April 3/1 3/2 3/10 May 4/3 4/3 4/7 June 5/1 5/4 5/12 July 6/1 6/1 6/9 August 7/3 7/6 7/14 September 8/1 8/3 … Read more

Health Plans, Patients Struggle To Pay for High-Cost Drugs Beneficiaries and physicians can be surprised and dismayed to find that in some drug classes in some plans, there is no preferred agent at all   Health plans appear to be using 20th century strategies to solve a 21st century problem. Faced with rising costs from … Read more

Medicare officials plan to launch a pay-for-performance demonstration project next year for solo and small physician practices. The initiative will be a pay-for-reporting program in its first year in order to provide baseline information on the approximately 800 participating practices in Arkansas, California, Massachusetts, and Utah, according to the Centers for Medicare & Medicaid Services. … Read more

Bundled payments, big data, and advances in personalized medicine will change the way primary care physicians and others practice David B. Nash, MD, MBA, envisions walking into his primary care practice and accessing an array of tools designed to help him provide the best, most cost-efficient care possible to engaged patient partners — and then … Read more

For Both Parties, Drug Costs Are a Hard Pill To Swallow This year’s two presidential nominees have taken aim at high drug prices — and pharma. A solution may require not just rhetoric but cooperation between industries.   This hasn’t been the best of years for the pharmaceutical industry on Capitol Hill. Even with pro-business … Read more

The popularity of loosely controlled benefit plans comes at the expense of HMO enrollment, which fell by more than 700,000 — about 1 percent — from July 1, 1999 to July 1, 2000. InterStudy Publications says HMO enrollment peaked at 80.8 million in July 1999. The heaviest losses came in the Southeast, where 928,000 people … Read more

This week, neglecting to satisfy its objectives at an endeavor between patients with diffuse large bcell lymphoma. The drawback Ensures that Celgene will not look for consent for Revlimid within this sign — probably the most typical kind of non-Hodgkin’s lymphoma accounting for a third of cases of this disorder. Revlimid was Not Able to … Read more

Even though total remuneration was relatively unchanged from 2008 to 2009, one expert thinks chief medical officers (CMOs) will be seeing more responsibility and will be “crucial in helping insurers meet their bottom lines,” says C. J. Bolster, a vice president and national director of health care practice at Hay Group, a global management consulting … Read more

Three-year projection Prescription drug spending will continue to rise between 13 and 18 percent annually over the next three years, with price inflation and higher utilization fueling the increase, Medco Health Solutions says in a new report. The Medco Health 2003 Drug Trend Report estimates that drug utilization will increase by 6 to 8 percent … Read more

If employers make decisions based on URAC’s and NCQA’s rating of traditional managed care plans, shouldn’t they want similar ratings of CDHPs? MargaretAnn Cross Contributing Editor When health plan accreditation organizations began taking note of emerging consumer-directed health plans in early 2003, the evolving insurance products were difficult to define. Today, as two major accrediting … Read more

Those with annual drug spend of $250K or more has increased by 60% Researchers at Prime Therapeutics say that number of “super spenders”—people whose drug costs are $250,000 or more—among the 17 million people it covers increased from just under 3,000 in 2016 to nearly 5,000 two years later. That works out to be about … Read more

California and other states have put monthly caps on out-of-pocket medication expenses. But the caps might shift some costs over to premiums. During the beginning part of year, people with high-deductible health plans who have large medical bills can end up shelling out thousands of dollars (up to $6,850 for individuals, $13,700 for families) before … Read more

New accreditation standards make it possible to do in physicians’ offices what’s now being done in hospitals — at significant savings Rock Rockett, PhD Linkedin Share ButtonTweet WidgetShare on FacebookGoogle Plus One MANAGED CARE May 2010. ©MediMedia USA New accreditation standards make it possible to do in physicians’ offices what’s now being done in hospitals — at … Read more

Imagine going to a doctor who doesn’t understand your language. You have to speak through an interpreter to describe your problems, give your medical history, and figure out what you’re being told by the doctor. That’s what 3 to 6 million working poor Latinos in California have to contend with — if they are lucky. … Read more

The Debate of Sandoz’s biosimilar was less focused on the basic principles of exactly what biosimilarity means and the way that FDA Requires these brand new services and products. Wednesday’s discussion focused more about extrapolation and postmarket surveillance to be sure that the biosimilar is beneficial in each one the signs it’s very likely to … Read more

B D and AI procedures contain learning that will be the purchase of Rules and information for utilizing the advice, reasoning that is implementing rules to accomplish approximate or concrete decisions and self-correction. This could help enhance the discovery of diseases, rare diseases, toxicity, and differentiating health system challenges resulting in under-diagnosis. This Informative article … Read more

A recent telephone survey of 300 physicians completing residencies in primary care suggested that when it comes to choosing a practice opportunity, today’s new doctors are swayed less by the financial perks they’re offered than by practice characteristics such as a favorable location. Neither a $12,000 signing bonus nor the forgiveness of educational loans would … Read more

Download supplement Respiratory syncytial virus (RSV) infection of the lower respiratory tract is the leading cause of hospitalization of infants younger than 1 year of age in the United States. Up to 126,000 infants are hospitalized each year for bronchiolitis or pneumonia, and close to 20 percent of these are premature infants. RSV hospitalization is … Read more

Alarm was raised within the planned role of pharmacists from the roll out of this COVID-19 vaccine application, that hasbeen directed forward by the us government to begin with mid-February, after Queensland Health’s forecasts for expressions of interest. RACGP Vicepresident and Chair of RACGP Queensland, Doctor Bruce Willett advised newsGP that the possibility is a … Read more

John A. Marcille Sometimes, following the changes in health care is like trying to take in several tennis matches at once. You might wind up knowing who won, but you’d be hard-pressed to say how it happened. Employers want to shift more of the financial burden to employees — hence the growing interest in consumer-directed … Read more

Severe Delivery Complications Soar Among U.S. Pregnant Women The rates of women experiencing serious and possibly life-threatening complications during child birth soared 45% between 2006 and 2015, increasing from 101.3 to 146.6 per 10,000 hospital deliveries, according to a statistical brief by the Agency for Healthcare Research and Quality (AHRQ). Megan Hambrick, a coauthor of … Read more

‘New’ Aetna and Kaiser Face Future The biggest for-profit and not-for-profit MCOs have been through rough times recently. How have their corporate cultures changed? Mergers, Acquisitions Afoot In Disease Management Industry Within a few years, there may be only 30 DM companies left, says one expert. HMO customers want vendors to handle more than one … Read more

MANAGED CARE December 2007. ©MediMedia USA Health insurance for all is essential, but not enough, says the Commonwealth Fund. In the report A High Performance Health System for the United States: An Ambitious Agenda for the Next President, it outlines strategies to contain costs and organize the health care delivery system…. An Ohio House bill may require … Read more

Officials at Harvard Pilgrim Health Care believe that they’ve responded to the soaring cost of drugs with tools already familiar to stakeholders: paying based on outcomes (for Enbrel), and paying based on value (for Forteo). Outcomes: Enbrel treats autoimmune diseases, most often moderate to severe rheumatoid arthritis. Under the two-year contract, Harvard Pilgrim’s payment for … Read more

Not too long ago, disease management was viewed with widespread suspicion. But the evidence mounts that well-designed programs make medical sense and can help patients as well as the bottom line. Let’s say you’re a managed care executive trying to sell physicians on the idea that disease management is a good thing, for both them … Read more

Also referred to as the Affordable Care Act or Obamacare, has been passed by Congress and party lines on March 2 1, 2010, also signed into law by President barackobama on March 2-3, 2010. The Senate passed on the ACA by way of a vote of 60-39 without a Republican aid on December 2-4, 2009. … Read more

Experimental drug targets body’s cannabinoid system Days after a phase 1 clinical trial studying an experimental fatty acid amide hydrolase (FAAH) inhibitor being developed by the Portuguese company Bial-Portela left one patient dead and five others hospitalized in France, numerous questions remain unanswered, according to an article on the BioSpace website. FAAH inhibitors are designed … Read more

The United States’ health care system needs consumer and market controls to succeed, but it can’t rely on only those two factors Jonathan Weiner wants you to know that, unlike some of his colleagues in public health circles, he doesn’t see managed care as the enemy. He notes that he is one of only a … Read more

Not-for-profit insurers contracting with physician groups provide better results, says one study. What can for-profit plans learn? Frank Diamond Managing Editor Assume that high quality care really does save money. Though that hasn’t been proven, much of what managed care does is based on that premise. Perhaps, though, the question is moot for there is … Read more

The FDA has issued a complete response letter (CRL) regarding the new drug application for Apadaz (benzhydrocodone/acetaminophen, KemPharm, Inc.), an investigational abuse-deterrent product candidate for the short-term management of acute pain. The FDA issues CRLs to indicate that the agency considers the review cycle for an application to be complete and that the application is … Read more

A patient’s ability to receive healthcare determined by the availability of services, their acceptability to the patient, the place of healthcare facilities, transportation, hours of operation, and cost of care. Sets of doctors, hospitals, and other health care providers, who voluntary work together to offer coordinated high quality care to their Medicare patients and also … Read more

Molina Healthcare of Michigan leans on education in effort to improve care for black men Aware that minority populations consistently receive lower quality health care services, officials at Molina Healthcare of Michigan decided that they just couldn’t live with it anymore. In 2006, only 7 percent of the approximately 4,450 African-American males covered in its … Read more

Salaries for staff pharmacists saw a healthy jump of 5.5 percent in 2005, compared to 2004. Median income for all Americans remained stable between 2002 and 2003, according to the latest figures available. The salaries of pharmacy team managers, staff pharmacists at mail order/online pharmacies, and clinical pharmacists, were collected and collated by Mercer Human … Read more

Introducing electronic prescribing systems and coupling them to formulary decision support (FDS) systems allows clinicians to prescribe preferred medications more frequently, according to a study involving two large Massachusetts insurers. Researchers at Brigham & Women’s Hospital found that those who used e-prescribing showed a 3.3 percent increase in prescribing tier 1 (generic) medications. The researchers … Read more

In May 1999, Abigail Sulerzyski was born deaf and blind with cerebral palsy and multiple other medical complications. While Victoria, her mother, was learning how to cope with the needs of a severely disabled child, she was also learning how to fight with UnitedHealthcare. Abigail required continuous feeding through a jejunostomy tube, and the insurer … Read more

Confronting The Medicare Cost Shift Plans are increasingly concerned about the degree to which providers overcharge them to make up for losses from government programs A Conversation With Michael L. Millenson: Health Care Reform Movement Has Only Scratched Surface This nationally recognized expert who has long been frustrated by the pace of change says that … Read more

Treatment achieves significant improvement in patients with inadequate response to biologics Positive results have been reported from a pivotal phase 3 study of baricitinib (Eli Lilly/Incyte Corporation), a once-daily oral medication under regulatory review for the treatment of patients with moderate-to-severe rheumatoid arthritis (RA). The study met its primary endpoint of an improved ACR20 response … Read more

The momentum in managed care has shifted to for-profit plans, but don’t count out not-for-profits, particularly these three innovative and — for many enrollees — beloved HMOs. They aren’t resting on their laurels. They were providing managed care before anyone called it that. But to make it through the turbulent late 1980s and early ’90s, … Read more

State Medicaid programs are weighing their options now that the Clinton administration has said they must cover medically approved uses of Viagra, Pfizer’s anti-impotence medication. States retain the option oflimiting the number of doses of the drug they’ll pay for, and last month New Jersey did just that. It imposed a cap of four doses … Read more

Released a last recommendation announcement and signs overview on clinicians utilizing visual tests to show adults to cancer. This is a I announcement and not really a recommendation for or against viewing. As the huge majority of skin cancers are all types which can be medicated and infrequently cause departure, melanoma differs. It’s a greater … Read more

The burden of diabetes just got bigger, according to epidemiologists at the National Institutes of Health and the Centers for Disease Control and Prevention. Nearly 13 percent of adults age 20 and older have diabetes, but 40 percent of them have not been diagnosed. An additional 30 percent of adults have pre-diabetes, a condition marked … Read more

Helped spark their nation’s opioid catastrophe by marketing pain killers, and has to cover $572 million into their nation. Oklahoma Hunted $17.5 billion, also attributing Johnson & Johnson for fueling the catastrophe that’s claimed the lives of over 6,000 people who are in the nation. It is the the first judgment to put on a … Read more

The Epi-pen was Devised in the 1970s with a Bio Medical Laboratory, Sheldon Kaplan, that was looking for a means to deal with allergic reactions immediately. What he came up was that the Epi Pen we understand now: a Pen-like apparatus that produces a premeasured dose of this hormone epinephrine in emergency scenarios. The gadget … Read more

Friends of Separate FDA advisers voted and Only Okay’ing Pfizer and Celltrion’s Accept the blockbuster inflammation Therapy Remicade for each one the benchmark drug’s approved signs, unswayed from protests in Johnson & Johnson. The bureau’s arthritis manager voted 21-3 in service of consent for Inflectra, also a biosimilar made by South Korea’s Celltrion along with … Read more

We have certified centers that do a great job for some patients, reducing downstream costs, but are of little benefit to others Under the radar screen for a very long time, stroke care and rehabilitation are changing dramatically, and that has major implications for managed care. After a stroke, 50 percent to 70 percent of … Read more

The FDA’s Gastrointestinal Drugs Advisory Committee has voted unanimously (17 to 0) to recommend accelerated approval of Ocaliva (obeticholic acid, Intercept Pharmaceuticals) for the treatment of patients with primary biliary cirrhosis, recently renamed primary biliary cholangitis (PBC). The target date for the FDA to take action under the Prescription Drug User Fee Act is May … Read more

Medicare needs a financial fix, and needs it badly. That fact hasn’t escaped the attention of any headline-browser in recent months. President Clinton and Republican congressional leaders have agreed on the outlines of a budget agreement that would cut the growth of the $170 billion annual program by $115 billion over five years. But the … Read more

Because readings in the clinic are unreliable and are a questionable guide to diagnosing and treating high blood pressure, self-monitoring deserves a look Lola Butcher Contributing Editor MANAGED CARE November 2008. ©MediMedia USA Because readings in the clinic are unreliable and are a questionable guide to diagnosing and treating high blood pressure, self-monitoring deserves a look Lola … Read more

Consumers pay a set fee for Internet service, cable and satellite television, health club memberships, and even all-you-can-eat buffets. Why should prescription drugs be any different? Researchers at Rand Corp. suggest a similar payment structure for prescription medication — with an annual license fee that would entitle consumers to a year’s worth of medication for … Read more

New Mexico has just granted medication-prescribing authority to psychologists — a development with broad potential implications for the field of mental health. I say “potential” because New Mexico is, after all, far from the centers of influence, and it’s possible no one will notice. But it’s a bold precedent. The intent is to allow better … Read more

Diet and exercise are increasingly seen as only the first steps in a journey that should include medication for weight maintenance Tom Reinke After an unfortunate run of bad luck with dangerous weight loss drugs, several manufacturers are on the verge of seeking approval for what could be a new generation of safer and more … Read more

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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

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

Many health plans see real value — financial as well as social — in screening for victims. MargaretAnn Cross Contributing Editor Tracking the hemoglobin AIC levels of diabetics or the number of heart attack victims who receive prescriptions for ACE inhibitors has become commonplace for many health plans. Mainly, that’s because good showings on such … Read more

Safer care Re: “Improving Care — 3 Success Stories,” March 2011. These examples demonstrate that focusing on care improvement as a primary goal can lead to both safer care and meaningful savings. This is important to health plans for two key reasons: It shows how plans can accomplish the triple aim of health care reform as … Read more

Clinical executives at health plans want to see how providers react to draft recommendation against procedure Frank Diamond Managing Editor “Watchful waiting”—that’s the managed care industry’s first reaction to the recent determination by the U.S. Preventive Services Task Force that prostate-specific antigen-based (PSA) screening may do more harm than good. Before adjusting their policies, health … Read more

Sure there are diagnostic and treatment challenges, but the money that can be saved for society might make this fertile ground for investment. Sure there are diagnostic and treatment challenges, but the money that can be saved for society might make this fertile ground for investment. Search the current literature and you will find a … Read more

Health plans have another option to consider for improving medication outcomes Thomas Reinke Health plans have not really bought into pharmacists’ claims that they can do more than pour, count, lick, and stick and that their role should be expanded into medication management or other aspects of patient care. Yet there is mounting pressure for … Read more

Listening to St. John’s Wort What’s a doctor to do when her patients embrace the untried and outlandish — sometimes with their insurers’ blessings? Doreen R. Orion, M.D. Genetic Testing: Handle With Caution Everyone involved seems to be grappling with ethical issues arising from the Human Genome Program. The science is still in flux. MARTIN … Read more

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A significant number of office-based physician practices have yet to implement an electronic health record (EHR), according to Sage Healthcare Division, a developer of EHRs. But their implementation “continues to grow as an increasing number of physicians and staff gain a better understanding of the efficiency and cost-saving benefits,” according to a recent company survey. … Read more

Lately I have noticed a few Democratic politicians protecting the present healthcare system by mentioning it averts”choice” to Americans. I used it all of the time being a market flack. However there is an issue. As a medical insurance policy PR guy, we now knew you of those huge”vulnerabilities” of this present system was insufficient … Read more

Anthem Blue Cross & Blue Shield bets that focusing on this portion of the individual market might be a good way to build brand loyalty Health plans for several years have been concentrating on individual members as a way to please their primary customers, employers. Some plans are now beginning to feel that focusing on … Read more

SNAPSHOT Paucity of PCPs may hurt children the most There are layers to the well-documented and much-fretted-over primary care physician shortage, a study in Annals of Family Medicine reminds us. The percentage of family physicians who care for children decreased from 78% in 2000 to 68% in 2009, and that presents challenges. ‘Family physicians, especially … Read more

In response to concern that there will be a shortage of physicians, the Association of American Medical Colleges (AAMC) recommends a 30 percent increase in U.S. medical school enrollment by 2015. A new report from the AAMC’s Center for Workforce Studies suggests that enrollment is on track to reach that goal, but by 2018, not … Read more

Is MA a ripoff of taxpayers, a godsend for integrated, cost-effective care, or somehow both? You can’t take a stand on this question from 30,000 feet. So let us guide you through the valley of details. In an old joke, a man sprinkles a magic powder to ward off elephants. “But there are no elephants … Read more

Total HMO enrollment grew 6.1 percent, to 76.7 million, during the last six months of 1997, according to InterStudy, which tracks HMO trends…. Enrollment in PPOs is soaring. The American Association of Health Plans says PPOs have added 44 million members in the last five years, while HMOs have attracted 30 million…. How many doctors … Read more

Europe Offers Example For Approving Biosimilars Insurers looking for some financial relief hope that the people who run the FDA’s review process take note John Carroll At the end of June, the European Medicines Agency (EMA) recommended approval of a pair of copycat versions of Johnson & Johnson’s blockbuster rheumatoid arthritis drug, Remicade. While Europe … Read more

Increasingly, health plans are providing disease, case, and utilization management when a beneficiary receives a cancer diagnosis By Lola Butcher See also accompanying story: Managing Cancer Treatment Begins Before Diagnosis Increasingly, health plans are rolling out services designed to help cancer patients and, before that, plan members at a high risk of cancer, to improve their … Read more

Cover Story 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 Joseph Burns Aiming at a Moving Target In Rheumatoid Arthritis As recommended treatment grows more … Read more

Physicians who make the move to the administrative side find a lot of tough decisions waiting for them. Marilyn Bydalek Quint Studer tells a story about his first day as the CEO at Baptist Hospital in Pensacola, Fla. back in 1996. When he asked a nurse what he could do to make her job better, … Read more

One of the key downsides of market-based health care  — that if your costs regularly exceed your income you go out of business  — is not typically associated with the National Health Service in the U.K. That is about to change. It has just been announced that the three hospitals that constitute the South London … Read more

That one region spends more on medical care than another doesn’t always translate into better health outcomes. What does make a difference is how those dollars are used, especially when it comes to hospital spending and care, according to a recent study in the Annals of Internal Medicine. “A managed care executive, who helps build … Read more

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 CMS go … Read more

The managed care industry is poised for a strong 2004, with profits projected to increase at least 16 percent, according to preliminary findings from “The Outlook for Managed Care, 2004,” a report prepared by Corporate Research Group, a health care publisher. Companies expecting to see double-digit increases in profits include Aetna, Coventry, Humana, Mid Atlantic … Read more

COVER STORY Tiger in the Fiscal Room: Beware the Increasing Cost And Number of Orphan Drugs While Congress worries about physicians’ salaries and employers bemoan the cost of imaging, it’s orphan drugs that might deserve most attention Ed Silverman Calling Something an ACO Does Not Really Make It So Many who claim to be constructing … Read more

PDF version:  MC_1407_peer_woundcare.pdf Abstract Purpose: As rates of diabetes escalate worldwide, diabetic foot ulcers are an increasingly significant public health problem. Advanced wound therapies that promote rapid and complete healing, thus reducing the risk for infection and amputation, can substantially improve quality of life while decreasing financial burdens to the individual and health care system. Our … Read more

EBM incorporates medical care and patient values with the very best available research details. It’s a movement that aims to boost the usage of top quality clinical studies into clinical decisionmaking. EBM needs new skills of the clinician, for example efficient literature-searching, and also the effective use of proper rules of evidence at evaluating the … Read more

Physicians providing most services in an office setting will benefit from the Health Care Financing Administration’s fee schedule for next year. Office-based physicians will receive slightly higher fees, up to a 1-percent increase, while most hospital-based doctors will see fee reductions of up to 1 percent. The changes are based on actual practice expenses; in … Read more

The increase in the costs of medical services for employers, sometimes called medical cost trend, is forecast to be 8.5 percent in 2012. The projection is from a report by Pricewaterhouse Coopers titled, Behind the Numbers: Medical Cost Trends for 2012. But benefit plan design changes will keep employers’ actual health care cost increases at … Read more

A newspaper series and a state audit put a spotlight on PBM practices in Ohio. Congress and other states are also looking more closely at what PBMs are delivering to Medicaid health plans. The business practices that PBMs use to collect a share of the drug industry’s profits are coming under close scrutiny like never … Read more

Though health plans preach it, the phrase doesn’t resonate with many physicians. But practicing it is not as difficult as many fear. Population-based care” is the managed care mantra. But ask physicians what it means, and most grope for a definition. “If you find out, let me know,” jokes Peter Juhn, M.D., executive director of … Read more

Providers Health care systems, hospitals, ACOs, & physician reimbursement reform, integrated delivery systems, & consolidation trends Demand for mental health services outstrips the supply of psychiatrists. Aggravating the situation: Many psychiatrists don’t take insurance. Nurse practitioners and physician assistants are beginning to fill the gap. By noon one day shortly after Thanksgiving, Kristi Kincheloe had … Read more

Insights from the promotion and instruction literature have been united to reevaluate government rationales and mechanics about the placement of contemporary students as consumers and also to gauge the influence on this procedure and outcomes of instruction, around the practitioner methods of faculty and about expanding involvement. Pierre Bourdieu’s conceptual framework is employed to reevaluate … Read more

The Meals and Drug Administration approved Zolgensma for kids under age of 2 using SMA, for example those not showing symptoms. The endorsement covers infants with the most peculiar type of this inherited disorder in addition to the ones with type s at which painful symptoms can place in later. “This Is possibly a brand … Read more

Expensive new drugs could drive spending in the cancer drug category by as much as 15 percent a year through 2013, according to a Medco report. That rate would place the category just behind diabetes and central nervous system treatments by 2015, according to the company’s Drug Trend Report, which tracks utilization and spending. “New … Read more

Before the election, it seemed that the health insurance industry’s worries in 2017 would include slimmer margins and affordability limits—employers and consumers might be hitting a wall on how much they can absorb in premium increases and out-of-pocket costs. And the antitrust fate of the proposed Aetna–Humana and Anthem–Cigna mergers loomed very large. With Trump … Read more

Bob Carlson “Physicians are always amazed when I tell them that only 50 percent of their work day is productive time,” says Sherry Delio, an expert in clinical practice work flow and efficiency. “They say, ‘I can’t believe that. I worked all day.’ I say, ‘Yes, but you had a lot of waits and delays.’” … 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

A controversial study challenges backers to prove that these technologies are cost-effective Richard Wootton expected some backlash. A professor at the Norwegian Centre for Integrated Care and Telemedicine in Norway, Wootton last year published a study in the Journal of Telemedicine and Telecare that challenges the industry to present scientific evidence that telemedicine works. Wootton … Read more

Following the Leaders Top pay-for-performance programs point to increased focus on hospital incentives, efficiency measures, coordination, and standardization MargaretAnn Cross Medicare Advantage Hits Jackpot with Private Fee-for-Service Plans The secret to the success of PFFS is as old as gold. Will beneficiary satisfaction force Congress to keep the faucet turned on? Frank Diamond Massive Databases … Read more

Plans will compete for new enrollees, including people with major health problems In early April, state officials in Ohio unveiled a new regional structure for Medicaid. In place of the eight zones it has now, they carved the state into three big markets: North, Central and Southeast, and West. And they tapped five plans — … Read more

Even though total remuneration was relatively unchanged from 2008 to 2009, one expert thinks chief medical officers (CMOs) will be seeing more responsibility and will be “crucial in helping insurers meet their bottom lines,” says C. J. Bolster, a vice president and national director of health care practice at Hay Group, a global management consulting … Read more

The Competitive New World of Medicare Managed Care With federal budgets tightening and the ranks of the elderly swelling, the managed care approach is expected to transform Medicare. What will this mean for HMOs and the physicians they contract with? ‘Prenuptial’ Planning for Your Next Managed Care Contract Signing with a managed care organization isn’t … Read more

A 20-19 payer poll of US health programs representing 105 million resides Indicates that 50 percent of Commercial payers call for a co insurance for specialty medication covered under medical benefit which will be as large because onequarter of their medication price. Even the Yearly prices for biologic treatment for Medicare patients also could be … Read more

eople today quit taking probiotic cholesterol-lowering drugs called statins, in accordance with a brand new U.S. study. And almost two in five find yourself carrying the medication in doses or less frequently than they have to the investigators report from JAMA Cardiology. Statins Comprise Lipitor, that will be sold as atorvastin, also Crestor, also called … Read more

Medical care providers and patients regarding the possible risk of disease by certain apparatus used during open center operation. Patients that have had open heart operation ought to seek medical attention should This information follows new information suggesting some LivaNova PLC Stöckert 3T heater-cooler apparatus, used throughout a number of these operations, may possibly have … Read more

More and more, physicians are balancing professional time with personal time through the use of part-time employment. A survey conducted by Cejka Search and the American Medical Group Association (AMGA) shows a rise in the number of physicians who practice part time. From 2005 to 2007, the percentage of all physicians practicing part time increased … Read more

EXAMINING ROOM A device hardly larger than an Rx pad may fare better than earlier versions of electronic prescribing. Vendors say learning to use them is a snap. Ed Rabinowitz The first computers were huge, often large enough to fill an entire room. Then came the personal computer — small enough to sit atop a … Read more

Washington Watch As fall settles over the capital, the Aug. 21 deadline for Congress to pass legislation regulating the use of personal medical data becomes a memory. Now, under the Health Insurance Portability and Accountability Act, the task of regulation development falls to the Department of Health and Human Services. HHS would rather see Congress … Read more

Pharmaceutical manufacturers pay rebates to pharmacy benefit managers and health plans as part of their formulary contracting agreements. The “2010-2011 Prescription Drug Benefit Cost and Plan Design Report” says that rebates are calculated as a guaranteed amount per prescription or an actual amount per prescription. The report says that there has been an increase in … Read more

COVID-19 has significantly altered the way in which we live and keep. Amid The chaos coronavirus has generated, individuals are searching for clarity and information by the organizations that they frequent on just how to protect themselves and also how to safeguard the others. Insurers have neglected to fulfill this requirement. Many consumers never have … Read more

A U.S. government agency, some argue, should be created to rule on usefulness of medications, equipment, and procedures. Britain has just instituted such a system. Frank Diamond Senior Editor “Health Care Should Be More ‘Transparent’” by Regina Herzlinger, PhD “Harness Information To Make Health Care Work” by Uwe Reinhardt, PhD “Something ‘NICE’ Can Come Out Of This” by … Read more

More than half of provider organizations surveyed by Evergreen Re, a national reinsurance consultant and broker, had at least one capitation contract last year — but use of capitation fell dramatically from 1999 to 2000. Perhaps not surprisingly, net profit, as a percentage of capitation revenue, for physician groups was down from 16 percent in … Read more

Steven Peskin, MD Three times during the past month a friend has asked for advice regarding his/her personal health care or that of a family member out of frustration and concern stemming from not receiving clear communication/information about the health problem(s). This scenario is all too common. Read moreabout Is There an Advocate in the … Read more

The health reform law makes collaboration between groups that are sometimes historically at odds not only easier, but necessary Cooperation between insurers and providers is no longer just an enlightened approach to health care. Health reform makes it a matter of survival. Look at one of the first studies to focus on the changes wrought … Read more

“Some people seeking to handle their weight might need a “Clinical trial statistics such as Contrave shows that new therapy, if used as a adjunct to some reduced-calorie eating plan and increased physical process, is actually a curative choice for a number of adults that are overweight with a comorbidityobese or fat. In my practice … Read more

Nearly everybody’s calling on the government to make health care coverage affordable and universal After years of public wrangling over health care reform, it turns out that there’s one point that just about everybody can agree on: Something has to be done about tackling costs and covering the uninsured. The problem of coverage and costs … Read more

Health plans are taking steps to implement this promising payment system, but it sure ain’t easy Joseph Burns About 40 health plans are implementing bundled payment programs and working to overcome the logistical problems inherent in changing how providers are paid. The system is attractive in part because in theory, it allows payers to control … Read more

Consumer-directed health plans (CDHPs, remember them?) experienced continued but slower growth this year, compared to 2009, according to the 2010 United Benefits Advisors Health Plan Survey. UBA is an alliance of more than 145 independent benefit advisory companies. UBA reports that CDHPs grew at a rate of 18.1 percent this past year (about half that … Read more

Mike Lee of Utah, Ron Johnson of both Wisconsin and also Ted Cruz of all Texas — published a joint announcement Thursday afternoon outlining his worries: “Currently, For various reasons, we’re perhaps not prepared to vote because of this particular bill, however we have been available to discussion and receiving additional info before it’s taken … Read more

  Username *  Spaces are allowed; punctuation is not allowed except for periods, hyphens, apostrophes, and underscores. E-mail address *  A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish … Read more

With big companies steadily reducing coverage for retirees, plans need to devise products for this needy population. In early March, managers at the giant auto supplier Delphi knew they were knee-deep in fiscal hot water. Their chief financial officer had just resigned after an audit pointed to accounting errors, and the company needed to make … Read more

The Hay Group’s annual benefits report found that health insurance premiums rose 5.2 percent in 1999, but not necessarily because insurers were trying to boost their bottom lines. Rather, the consulting firm attributes most of that rise to the soaring cost of prescription drugs — up 15 percent, by Hay’s estimate. Though the year began … Read more

This paper presents the full pile model-based elastic instance management system customized for health domain ap- plications. The machine design and development have been driven with the Personalized Connected look after Sophisticated Oral Patients (CONNECARE)inch endeavor. The aim of all CON- NECARE would be always to develop the efficacy of integral maintenance systems and healthcare … Read more

Specialty drugs are the most expensive drugs on the market, with prices that can range from $5,000 to more than $30,000 per year, and in only a few cases are the prices falling, according to a report from the AARP Public Policy Institute, which looked at 144 specialty drugs widely used by Medicare Part D … Read more

By Mark Hochhauser, Ph.D. Managed care is complicated, so it’s not surprising that “average” Americans have a hard time reading and understanding documents from their health plans. Yet it is possible to convey the information clearly. The 1993 National Adult Literacy Survey studied prose literacy (skills needed to understand and use information from texts), document … Read more

Compensation continues to increase for most physician categories in academic medical settings, according to a survey by the Medical Group Management Association. Last fall, MGMA surveyed 513 clinical science departments in 101 medical schools and found that median compensation was up for both primary care and specialist faculty. All primary care categories rose 1.7 percent … Read more

Many physicians are falling short when it comes to reporting test results to patients, a recent study shows. Such lapses could hurt both doctors and health plans in the quest for good patient-satisfaction scores. Jean Lawrence Contributing Editor Would you believe that one in three physicians has no set policy for informing patients of abnormalities … Read more

From 2004 to 2015, health care spending is projected to remain relatively stable, with continued growth projected to be about 7.2 percent per year on average. Despite substantive revisions to the historical National Health Expenditures data (e.g., determining the value of structures and equipment in a medical professional’s office) and a new model for private … Read more

Report authors foresee 10% to 12% jump in hospital spending in 2016 A sharp rise in prescription medication prices—driven by the introduction of new, expensive specialty medications and huge increases in the costs of older drug products with few competitors—drove an 11.7% increase in hospital and clinic spending on medications in 2015, according to a … Read more

By Frank Diamond Senior Editor   When Rick Millard, Ph.D., made a presentation at the Data Integration and Analysis for Disease Management conference in March, he probably didn’t dream that the reaction would be so intense. Millard, vice president of clinical affairs for Patient Infosystems in Rochester, N.Y., reported preliminary findings on his company’s CareSense … Read more

Only half to three-fourths of stroke survivors who had been discharged from the hospital were still using preventive medication two years later, according to a large Swedish study published in Stroke: Journal of the American Heart Association. This disconcerting finding can be seen as an opportunity that health plans can take advantage of by providing … Read more

Sufficient confidentiality needs to be assured before a nationwide system will be ready for implementation Several weeks ago, Paul Feldman, the cochairman of a Department of Health and Human Services advisory group on technology, handed in his resignation and headed for the door. On the way out, he and a colleague at the Health Privacy … Read more

Cost is still the overriding concern, but some cutting-edge companies have been asking HMOs to meet specific administrative and clinical goals. As Marriott International works to renew contracts with HMOs for next year, it is requesting that health plans agree to specific clinical targets. The Washington, D.C.-based hotel chain is working with 80 HMOs to … Read more

Even when, as Looks Possible, the bill Endorsed by House Speaker Nancy Pelosi,” D-Calif., will not be signed in to law, the current vote was still important. Years of lobbying and people have forced lawmakers to behave and it has knocked the pharmaceutical industry on its insides. The initial bill would have just labeled 25 … Read more

Nearly all health plans intend to increase business process automation in the next two years, primarily to decrease errors while increasing productivity, according to a study by First Consulting Group. The survey of 65 health insurers includes national as well as regional plans ranging in membership from as few as 1,000 to over 3 million. … 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. Campion Quinn, M.D. A MEDICAL DIRECTOR’S VIEW HMO medical directors are caught in a Catch-22. We have to juggle the financial … Read more

John A. Marcille You know the saying about giving someone a fish as opposed to teaching him to fish. Well, a lot of consumers are going to feel that the medical industry has told them to go fish, and forgot to include the lessons. Enter the health plan. Our cover story by Contributing Editor MargaretAnn Cross shows … Read more

Just about everyone except the patient is offering some kind of incentive to do something, but beware of unintended, not to say unwanted, outcomes: the notorious perverse incentive The influence of incentives in our lives can possibly be overstated, though that would take some doing. The world-famous health care economist Uwe Reinhardt, PhD, says, “I … Read more

Employers are adopting disease management programs in a big way to slow the pace of health care premium increases, according to a survey of 3,000 businesses. This is just one of the elements of an unexpectedly positive report by Mercer Human Resources that shows that health care premiums in 2003 did not grow so much … Read more

There are two transformations occurring in workplace based health promotion in America. The first is the movement from wellness to “well-being” and, related to this, a shift from a focus on a return on investment (ROI) to the use of value on investment (VOI) measures. These VOI measures are well documented and publicly available, but are we … Read more

Health plans need to take a closer look. HMOs and employers alike will feel increasing pressure to give in to the desires of consumers. By Steven S. Martin Blaming any one group or industry for rising drug costs is not a useful exercise. Like the “energy crisis,” rising drug costs result from problems with the … Read more

Retail pharmacies are less likely to dispense specialty drugs than in the past, according to the Pharmacy Benefit Management Institute’s 2009-2010 Prescription Drug Benefit Cost and Plan Design Report. In 2007, nearly 37 percent of employers surveyed said their plan benefit design allowed retail pharmacy to dispense specialty drugs, but that dropped to 28 percent … Read more

Lawsuit Claims Sexual Dysfunction Drug Cialis Tied to Skin Cancer PDE5 inhibitors may increase risk of melanoma   Seven men who were treated with Cialis (tadalafil) tablets for erectile dysfunction have sued Indianapolis-based Eli Lilly and Co., claiming that they later developed skin cancer that was related to the medication, according to a report in … Read more

Almirall, S.A, today reported that the Food and Medication Organization has affirmed the new medication application for Duaklir, for the therapy of patients with constant obstructive pneumonic sickness. Duaklir® offers a fixed-portion blend of a novel long-acting muscarinic adversary, aclidinium bromide and a quick long acting beta2-agonist, formoterol fumarate, regulated through the GENUAIR® inhaler gadget. … Read more

BY TIMOTHY KELLEY I once did some volunteer work for an idealistic young candidate who was running in a primary against a man I’ll call Congressman X. X, an influential legislator, had been tainted by the Abscam scandal of the late 1970s, and that perceived vulnerability had also drawn two latecomers into the race. I … Read more

Frank Diamond Last year’s fiasco at Penn State represents just one crack in the wellness armor. Worker resentment rises as experts begin to question the effectiveness of such programs. But employers still believe and so long as there are buyers, there will be sellers. Continue reading… News & Commentary Wellness Benefits Not in the Mind … Read more

BlueCross BlueShield of South Carolina anticipated the problem years ago and invites you to join in what could be a solution Frank Diamond Even a slow-moving disaster that everybody — and we mean everybody — sees coming garners headlines. Heaven forbid that the astronomers discover the big one: the huge asteroid on a collision course … Read more

I try to be receptive to new ideas. I really do. After several years covering managed care, I’ve watched quite a few run up the flagpole, only to see them unceremoniously lowered for lack of salutes. Sometimes I buy in. Later I’m embarrassed because I didn’t think the issue through, or mystified that others didn’t … Read more