CONTRIBUTING VOICES There are people who think health care costs are about to decrease! John Marcille I was just looking at the website of Newtek Business Services (www.thesba.com/), which also goes by the name of The Small Business Authority. It sells financial and administrative services to small businesses. I found more evidence that the public … Read more

The rate of increase of health care costs was less over eight years for beneficiaries enrolled in a value-based program in which participating physicians took on two-sided risk, compared with a control group seen by providers with traditional contracts, according to a study published in the New England Journal of Medicine. In addition, those beneficiaries saw … 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

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

Many serious diseases which may be screened for at birth aren’t contained in regular newborn genetic evaluations. Total genome sequencing of teens to get present and possible ailments have become technologically possible and may soon be economically viable. Researchers are researching whether the consequent flood of genetic information will help physicians and parents care for … Read more

A management system that encourages employers to better examine factors that influence workers’ health and well-being — thereby cutting health-related costs — has garnered some praise and much expectation. The key phrase is health and productivity management, which those who practice it reduce to HPM. In 1997, 15 so-called best-practice companies analyzed their HPM data … Read more

Debating RICO Suits vs. Health Plans Donald P. “Rocky” Wilcox Making the Case for a ‘Health Care Fed’: Should Uncle Sam Decide What Works? 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 When Physicians’ Skills Fail, … Read more

The way to reduce errors in health care is to change systems, says this Harvard educator. Punishment encourages people to cover up. Lucian L. Leape, M.D., is a health policy analyst whose research has focused on error prevention and appropriateness of care. Prior to joining the faculty at Harvard, he was professor of surgery at … Read more

The timing was right for America’s Health Insurance Plans to unveil a proposal last month that would cover all children and nearly all adults in the country, says Mohit Ghose, the lobbying association’s spokesman. The $300 billion plan garnered headlines. The AHIP proposal would: Have Medicaid cover all adults with annual incomes less than the … Read more

The American Medical Association has voted to form a: Wednesday morning golf league Drive-through morning checkup service National doctors union Frequent-patient program — Chicago Tribune, 6/27/99 This is the public’s attitude regarding physicians and unions. For anyone who doesn’t believe it, think about basketball and the public’s tolerance for star salaries. Do individuals do well? … Read more

Health Reform and the Use of Financial Incentives in Wellness Programs Affordable Care Act Financial incentives Health Reform Outcomes based incentives Progress based incentives Wellness The Affordable Care Act codified the worksite wellness exemption to the federal medical underwriting provisions in the group health plan market. This means companies are allowed to use an “outcomes-based” … 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 a variety … Read more

Blame Hollywood. Or, at least, partly blame Hollywood. (We’ll take what we can get.) Women ages 30 to 55 too often ignore the warning signs of an acute myocardial infarction (AMI), according to a study in Circulation: Cardiovascular Quality and Outcomes(link is external). They either don’t recognize more nuanced symptoms (dizziness, aching muscles, indigestion, fatigue), or they … Read more

More and more, PPOs are coming under scrutiny, according to InterStudy Publications, which found that 40 states have passed some level of PPO regulation. That’s a big increase since 1992, when only a dozen states had regulations specific to PPOs…. Cost remains the major factor that small employers weigh when deciding whether to offer benefits, … Read more

AHRQ’s director of health care information technology looks at the federal health care IT stimulus program from the quality perspective A year after the stimulus bill called for an investment of billions of dollars for health care information technology, and with newly defined government incentives to providers in play, it’s clear that the use of … Read more

Tomorrow’s Medicine While biologic agents can be costly, a new formulation of an old treatment can mean inexpensive and effective relief Thomas Morrow, MD A recent Wall Street Journal editorial was titled “Health Care or a House.” It discussed the fact that an average house payment is approximately the same as the cost of the … Read more

Managed care’s strong points, obscured in the backlash over choice and coverage decisions, will be critical to consumers in the years ahead. Having lived with Crohn’s disease for 20 years, medical emergencies are part of my life. But when- ever I have to visit the emergency room of my local hospital, a top-ranked facility in … Read more

Monthly convulsive seizures significantly reduced Positive results have been reported from a phase 3 study of the investigational medication cannabidiol (Epidiolex, GW Pharmaceuticals) in patients with Dravet syndrome, a rare and debilitating type of infantile-onset epilepsy for which no treatments are currently available in the U.S. Cannabidiol achieved the trial’s primary endpoint of a significant … Read more

Improving cardiac surgery outcomes for both adults and children is the goal of 21 quality measures recently endorsed by the National Quality Forum. The measures spring from two NQF “endorsement projects”: Surgery Endorsement Maintenance 2010, Phase 1, and the National Voluntary Consensus Standards for Pediatric Cardiac Surgery. “NQF endorses national consensus measures in health care … Read more

Joyce R. Ochs When the American Medical Association published e-mail guidelines for doctors last year, it was a tacit acknowledgment that the ubiquitous medium had found a place in the mainstream of medical practice. The issue today is no longer whether to do it (it’s being done) but how doctors will use e-mail in the … Read more

To Evaluate the operational and economic effects of executing a shorted diagnostic pathway during flu epidemics. Differences at room occupancy period at the ED and inpatient ward and also expenditure differences were computed to get its 14-week flu season. The process flow has been streamlined with the RDT pathway, and also the essential isolation period … Read more

Hospital at home is an Atmosphere in Which chosen kinds of healthcare might be delivered at your house to acceptable, consenting patients that require in patient clinic maintenance. Increasing financial pressure in hospitals, in addition to patient choice, has driven the evolution of HITH like a workable choice for supply of acute care, both in … Read more

This analysis has become the most exhaustive test of the cardiovascular hazard of rosiglitazone in history. It will help regulate blood glucose in patients who have type 2 diabetes, however it may also raise the probability of severe cardiovascular issues. This has caused suspension of this medication from Europe and beyond constraints in its usage … Read more

Before an vague sub section of this pharmacy industry, specialty pharmacy is currently a field that a lot of medical care professionals comprehend. Specialty services and products currently dominate the medication pipeline, with gained greater blessings than conventional medications since 2010. Specialty medications would be the significant cause of greater drug spending, that is likely … Read more

Group Health Cooperative researchers say plans that provide full coverage of smoking cessation programs do so wisely. At $328 per person, they wrote in a Sept. 3 New England Journal of Medicine study, such programs are cheaper than hypertension and heart disease — which carry average annual costs of $5,921 and $6,941 respectively…. Highmark has … Read more

By James Schultz To introduce the latest addition to his professional family, Randy Axelrod, M.D., reaches not for a desktop photo but for a computer keyboard, then scrolls effortlessly through the names of patients, their ages, genders and diagnosis codes. The program he shows off is a healthy toddler, 18 months old. Like any new … Read more

By Frank Diamond Managing Editor Uncle Sam isn’t too sure that disease management saves money in the managed care world, and has some real doubts that it could ever be applied to Medicare. At least, those are the findings of a Congressional Budget Office study that has proponents, critics, and observers of DM talking. The … Read more

The Value of Drugs: It Is Not About the Money! Interview by Peter Wehrwein inShare Tweet Widget (link is external) Boston comparative effectiveness organization ventures into drug reviews and sounds the alarm if the price is high. The Institute for Clinical and Economic Review (ICER), a comparative effectiveness research organization in Boston, received a $5.2 … Read more

By David L. Coleman, J.D. Contributing Editor It goes by lots of fancy-sounding names: “deselection,” “disenrollment,” “downsizing” and “rightsizing.” But no matter what it’s called, getting dropped from a managed care network spells trouble for physicians. When managed care companies move into a virgin area, they tend to sign up as many doctors as possible. … Read more

TOMORROW’S MEDICINE A single strand of nucleic acid may hold the key to treating the leading cause of severe vision loss and blindness resulting from age-related macular degeneration. Age-related macular degeneration (AMD) is a chronic progressive disease of the macula that causes central loss of vision. This disease starts with a central blurred or blank … Read more

Is it worthwhile for even a computer-shy physician to spend a little time investigating the Internet and other online services? You bet it is. Here are some of the ways these resources can work for you. Anne Bilodeau Contributing Editor To a technophobe, “cyberspace” may seem as foreign the surface of Mars, and almost as … Read more

Accountable care organizations (ACOs) are implementing population health programs nationwide. This trend has been building momentum since the Affordable Care Act became law in 2010. As physicians and hospitals form ACOs, however, they may be missing an important element of population health: the management of health care risk, says Jay Sultan, the vice president for … Read more

Narrowly now and only advocating that an expanded signal for empagliflozin which could say the diabetes medication reduces the chance of cardiovascular disease. Evenly divide on the voting dilemma about the grade of evidence behind the cardiovascular mortality sign for empagliflozin. In general, 12 panel members believed that the data given substantial evidence in demonstrating … Read more

An Easy and Profitable Way to Turbocharge Disease Management? data management data privacy Disease Management Disease Management health policy medical informatics Al Lewis When an employer group shifts from one health plan to another, why not allow them to take their claims data to the next health plan? That way, the new plan would gain … Read more

In 2010, most Medicare Part D plans are not offering gap coverage. This amounts to $3,610 in drug costs per member for plans offering the standard Medicare Part D benefit. By 2019, the gap is projected to widen to nearly $6,000. Seven of the 15 national PDP sponsors do not offer gap coverage in any … Read more

For-profit, investor-owned health plans are setting the growth pace these days, and some nonprofit plans are switching to for-profit status to keep up with the competition. But are the two kinds of plans really so different?   Tune your dial to National Public Radio, flip to Harper’s May cover story, or read the New England … Read more

Privately Held Harmony Bio-sciences just Borrows Consent by the U.S. Food and Drug Administration Because of its Very First Business Solution, a Remedy for narcolepsy. Maybe not just will be it Wakix the earliest business product to Harmony bio-sciences, however, it is, in addition, the very first remedy method for narcolepsy accepted from the FDA … Read more

It’s one thing to encourage efficiency on the technical side, but do you really want your radiologist to read 50% more scans or X-rays per hour? John Carroll Contributing Editor Just like every other payer in the country, Medicare has been looking for the best approach to reining in the high cost of imaging. And … Read more

With the ever-rising cost of prescription drugs generating an outcry to reform Medicare, PhRMA’s president finds himself in the eye of the storm. As president of the Pharmaceutical Research and Manufacturers of America, Alan F. Holmer represents the country’s largest research-based pharmaceutical and biotechnology companies. The organization lobbies on behalf of its members in Washington … Read more

Lax regulations and fee-for-service payment make an irresistible mix for physician conflicts. Are ACOs the answer? Almost 50 years ago economist Kenneth Arrow warned about agent moral hazard — the temptation for physicians to exploit their knowledge edge over patients for economic gain. Today, physicians are bombarded with potential conflicts of interests between their obligations … Read more

This is the first time that a simple blood sample from a vein has replaced an invasive biopsy of a major organ Thomas Morrow, MD The first heart transplant was performed in South Africa over 40 years ago by Christiaan Barnard, but even today, few readers of this column have ever met a person who … Read more

Although effective treatments are available, helping patients cope is a minefield of administrative and legal barriers The World Health Organization states that 85 to 90 percent of cancer pain can be controlled with drugs, but according to a study by the Institute of Medicine, “for many Americans with cancer, there is a wide gulf between … Read more

Attempts to replace radiology benefit managers with a more doctor-friendly system show success Proponents of clinical decision support (CDS) systems believe these tools are capable of putting utilization reviewers out of business. In the first skirmish in what could be a long war, physicians in Minnesota have developed a CDS system that is used at … Read more

The Patient Protection and Affordable Care Act provides new initiatives to fight crooks and opportunists Any meaningful discussion of health care fraud quickly reveals two fundamentally troubling realities. First, this seemingly straightforward topic becomes not one but three, commonly referred to as fraud, waste, and abuse (FWA) — a continuum of sorts without specific boundaries. … Read more

Tennessee Gov. Don Sundquist wants a $400 million tax increase, much of which would keep TennCare, the state’s managed Medicaid program, from “imploding” — as put by its director, Brian Lapps. An actuarial study found that TennCare, which covers nearly a fourth of the state’s residents, is $289 million underfunded. Lapps says TennCare needs to … Read more

The staff model used to define the HMO. Now it’s almost gone. But wait — maybe it’s not the model that died, but the usefulness of the classification. The shock was profound. When you thought about HMOs, you used to think about staff-model HMOs; everything else was mere variation. Yet here was InterStudy Publications’ HMO … Read more

Way back when, credentialing was something done only by hospitals. Now, nearly every health plan must do a check on every physician. The AMA has a plan to lighten the burden. But will it work for all parties? Getting all physicians on the same page when it comes to credentialing and quality measurement is a … Read more

Disruptive Innovation If they can adapt, payers will have far more power than fragmented physicians, other providers, employers, and patients to shape the new environment Stephen Wunker David Duncan While the health care policy debate in Washington continues to center largely on who is provided insurance coverage, managed care organizations know that the primary business … Read more

New study puts price of 10 cancer drugs at $648 million each What’s the price tag for bringing a drug to market? The standard answer, based on a study by the Tufts Center for the Study of Drug Development, is $2.7 billion. But not all experts are convinced that’s the correct total, and a study … Read more

ICUs are expensive, intensivists in short supply. Bringing telemedicine to the ICU may help the situation, but doubts linger about what that will achieve. Picture this scene: A middle-aged man who is having difficulty breathing is brought to the emergency room of a community hospital. His condition is serious, and he is immediately put on … Read more

Plan Watch The insurer’s tracking effort helps physicians keep tabs on patients who may not be taking their drugs correctly Frank Diamond When PricewaterhouseCoopers released the study “Advancing Healthcare Informatics: The Power of Partnerships” in September, it included some case studies of health plans that seem to be doing a good job of using the … Read more

Of Clovis Oncology’s experimental lung cancer medication, rociletinib. The FDA isn’t needed to adhere to the committee’s vote however frequently does. Clovis Oncology CEO Patrick Mahaffy stated in a declaration that the Company was frustrated with the panel’s refusal also certainly will utilize the FDA to”appraise the most useful forward since it has been critique … Read more

Companies will want to distance themselves from insurance entanglements, giving employees little option but to become more involved. Meanwhile, stormy seas ahead for Medicare+Choice. What’s going to happen in employer-provided health insurance in the first part of the next millennium will be a radical shift from what is now essentially a defined-benefit scheme — where … Read more

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

Medication Coupons sound great written down for both manufacturers that sell more services and products and also for patients who pay to get a pricey fresh item. But, payers and pharmacy benefits managers aren’t impressed. Nothing is free of charge. That applies to manufacturers’ medication vouchers which may lure consumers into using anti-seizure drugs over … Read more

No longer passive, companies are working in a variety of ways to improve employees’ care. Are health plans being left behind? Helen Darling calls it “revolutionary,” this effort on the part of employers to more closely monitor and improve the health of their workers. Darling, the president of the National Business Group on Health, which … Read more

The consumer-directed model isn’t taking the country by storm, but its innovations are influencing other coverage designs When several start-up companies launched consumer-directed health plans more than a half-dozen years ago, terms like “incremental change” didn’t come up much. “The founders of consumer-directed health care always saw this as a transformational strategy that would improve … Read more

The breed of germs isolated from 2014 in the 76-year-old person with a While this breed did answer some other anti inflammatory agents and has been treated successfully, researchers say that the case introduces a solid reminder to both track and track multidrug-resistant organisms. “The Great news is that this didn’t lead to a major … Read more

Low reimbursement wasn’t the only — or even the primary — factor behind HMOs’ Medicare pullout last year. The General Accounting Office has concluded that “although an unusually large number of managed care plans left Medicare, a number of new plans have demonstrated their interest in serving beneficiaries by applying to enter the program.” The … Read more

It doesn’t look good for primary care, with shortages of doctors now and greater shortages expected, plus the high cost of medical school. Graduate school education costs are on the rise, especially in the fields of medicine, law, and business. In particular, medical school tuition and educational debt levels have risen faster than the rate … Read more

“Problem recognition” is what Cigna appears to be going through, as the company’s stock continues to fall and analysts predict that a turnaround may take longer than originally hoped. “The company is still getting to the bottom of how bad the problems really are, and we remain unsure as to when that bottom will be … 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

Those who choose these plans tend to be more educated and dedicated to maintaining healthy lifestyles Frank Diamond Managing Editor The Employee Benefit Research Institute recently went looking for what many hope to be one of the bulwarks of a new, cost-effective health care system — the “engaged consumer.” The institute found him in two … Read more

Bush has one year to deliver change, as promised. Medicare, prescription drugs, malpractice insurance are all on the table. Within the Beltway, the word has gone out: This is President George W. Bush’s second 100 days. Fresh from being hailed for leading the way to a slim Republican majority in the Senate, President Bush has … Read more

Follow this link to PDF version Do patients with differing conditions have different experiences within the health care system? A sampling of California patients suggests that they do. The Health Rights Hotline, a Sacramento-area organization that provides information about and assistance with the health care system, found common threads among patients with diabetes, cancer, mental … Read more

Three of the top four HMOs in the Newsweek and U.S. News surveys are in Massachusetts. What the surveys don’t tell you is that all three highly regarded HMOs — Fallon Community Health Plan, Tufts Health Plan, and Harvard Pilgrim Health Care — are on the Massachusetts Department of Insurance “watch list” because of shaky … Read more

MANAGED CARE June 2006. ©MediMedia USA Tomorrow’s Medicine Although Myozyme is approved for the infantile form of Pompe disease, it is logical to extend coverage to patients with the late onset form Thomas Morrow, MD For most of us in managed care, the mention of Pompe disease is likely to bring back long-faded memories from a genetics, … Read more

John Marcille I don’t know about you, but I’m starting to be overwhelmed by the complexities of the Affordable Care Act, and that’s just the parts of it that interest me. One of those parts is the mandate for health plan purchasing exchanges in the states. All I can say is that I would not … Read more

Whatever Happened To Exclusive Contracting?  36 A few years ago, experts predicted that HMOs would be lining up exclusive “teams” of primary care physicians, specialists and hospitals. Was that prophecy wrong, or is its fulfillment just delayed? Pioneer Not-for-Profit Plans Struggle To Remain Leaders   48 The momentum has shifted to for-profit plans, but don’t count out not-for-profits, … Read more

The target of the growth means of biosimilars would be always to reveal resemblance to the benchmark product as opposed to patient benefit per se, since it is created for its RP. The evolution method is a step wise procedure that starts with a relative analytical characterization and also a extensive operational and pre clinical … 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 unwanted term ‘the nervous’ will be used, especially by policy makers now by some clinicians too. Ordinarily, it refers to a set of patients that are regarded as with medical services inappropriately or , when other deserving patients ought to receive care. It thus reflects the older notion of this deserving and undeserving poor, … Read more

Though the growth in the number of consumers opting for coverage through plans that use health savings accounts (HSAs) as well as the growth in the number of insurance companies that offer such plans is impressive, the absolute numbers of those electing such coverage remains relatively small. More than a million people used HSAs as … Read more

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

HMO premiums for 2004 will be up about 18 percent, according to preliminary data gathered by Hewitt Associates. Despite the continued double-digit climb, researchers believe that the rates might be starting to moderate. About 140 employers, representing nearly 1 million workers, are negotiating rates at about 17.7 percent compared to 21 percent at the same … Read more

Outlook According to researchers, health spending growth will slow over the next 10 years, both private and public. Per-enrollee private health insurance benefit growth peaked in 2001, but per-enrollee premium growth did not peak until 2002. In addition, the number of people with private health insurance will begin to increase again in 2003. This projection … Read more

Sutter Health, an integrated health system of 26 hospitals and 5,000 physicians in California, is using capitation to encourage greater cost-effective care. But it’s not Sutter’s primary care physicians who are being capitated. When Sutter finishes work with its medical groups on a new payment scheme, primary care physicians will be paid on a fee-for-service … Read more

Microscopic structures look and move like bacteria For the past few years, scientists around the world have been studying ways to use miniature robots to treat a variety of diseases. The robots are designed to enter the human body, where they can deliver drugs at specific locations or perform precise procedures, such as clearing clogged … Read more

NEWS & COMMENTARY Electronic Health Records Bolster Diabetes Outcomes When Kaiser Permanente Northern California rolled out a new electronic health record (EHR) system for outpatients a few years back, a team of researchers considered it a golden opportunity to evaluate how such systems affect care and outcomes. The staggered implementation of the EHR system at … Read more

Nine instruments were reviewed based on the extent that they measured the four attributes of primary care. Only one fully met the recommended criteria. Full text in PDF Abstract Purpose: The patient-centered medical home is evolving as an approach to providing primary care. Primary care is defined by four main characteristics: comprehensive, coordinated, continuous, and accessible … Read more

Humana reported that its congestive heart failure disease management program, run by Cardiac Solutions, reduced inpatient expenses 61 percent…. Sierra Health Services finished its acquisitions of Kaiser Foundation Health Plan of Texas and Kaiser’s Texas Permanente Medical Group. Sierra renamed the HMO Texas Health Choice…. Kaiser, meanwhile, said that its California arbitration system will now … Read more

Aetna U.S. Healthcare will launch a series of products Jan. 1 that will drop the gatekeeper function. In most cases, the new plans, called Aetna Open Access, will allow members to receive care from specialists without a referral from their primary care physicians. Meanwhile, HealthPartners, the Minneapolis-based health system and HMO, plans to offer its … Read more

Paul Ellwood, M.D., who is generally recognized as the father of managed care as we know it, envisioned a world of health care delivery that featured HMOs with exclusive teams of physicians. The HMOs — and, indirectly, their physicians — would compete less on price than on quality of care and the ability to achieve … Read more

This Group consists of Files Associated with Hillary Rodham Clinton’s The files comprise reports, memoranda, correspondence, programs, and news postings. What’s more, this material incorporates draft reports by the White House medical care Interdepartmental Working Group, made to notify that the Health Care Task Force within the reform program. Even the Nixon team has been … Read more

We know Watson, the supercomputer, for its vast fund of knowledge and thinking prowess when machine bested man, defeating the all-time Jeopardy champ for games won, Ken Jennings (74), and Brad Rutter, Jeopardy’s highest money winner ($3,470,102), and winning against Jennings in a head-to-head Tournament of Champions. Now, Watson is flexing her considerable problem-solving muscle … Read more

NATIONAL POLICY Gore, Bush, McCain, and Bradley differ in some of the details. None of them really stands out from the crowd. Michael Levin-Epstein When it comes to managed care issues and the four leading candidates for president, the differences are in the details. Although there are some variations in health care policy between Vice … Read more

MANAGED CARE December 2005. ©MediMedia USA Health plans, researchers, employers, and workers make common cause to identify and treat depression Lola Butcher When Sprint Nextel, Hallmark Cards, and other Kansas City area employers decided to work together on a single health problem, step one was to survey workers about health risks. Step two was to pick a … Read more

Not surprisingly, many uninsured adults either do not get or postpone care they need. But a recent Kaiser/Commonwealth Fund survey suggests that adults who receive Medicaid benefits also skip or put off care — and that, because of expense, adult Medicaid patients are less likely to fill prescriptions than those without insurance — despite the … Read more

Although the controversial medical savings account concept lost a staunch congressional supporter with Senator Robert Dole’s announced resignation from the Senate, the next step for the pending health reform measure–a House-Senate con- ference committee–has not changed. The conferees had not been appointed at this writing, but composition of the conference committee is of sharp importance … Read more

More employers and plan managers are looking at offshore options, but few are taking the plunge Four years ago Thomas Hiland, a suburban Denver businessman, needed mitral heart valve replacement surgery. He could have gone to the University of Colorado Hospital, or the Mayo Clinic, or the Cleveland Clinic. He chose instead a 15-hour flight … Read more

Aetna’s profits more than doubled in the fourth quarter of 2003, rising to $249.5 million, or $1.56 a share, from $98.2 million, or 63 cents a share a year earlier. The insurer attributes the results to its ability to hold the line on medical costs and cut operating costs…. U.S. health care spending increased to … Read more

The TNF-α blocker is the world’s top-selling drug, by revenue. It faces biosimilar competition in Europe, but it will be four years before it’s challenged in the U.S. Many rheumatoid arthritis sufferers are getting relief from their pain with Humira, but it’s likely to take until 2023 until they get any relief from the hefty … Read more

With the approval of Breo Ellipta in May 2013 and Anoro Ellipta in December 2013, formulary decision makers are faced with more treatment options for chronic obstructive pulmonary disease (COPD) than ever before. There are now three inhalers that are combination products of a long-acting beta agonist and a glucocorticoid that can potentially help patients … Read more

Specialty meds will put pressure on overall costs Krishna Rutvij Patel, PharmD Health spending is climbing steeply this year, but the rate of increase should start to slow beginning in 2015, according to a recent report by the Centers for Medicare & Medicaid Services (CMS). The combination of an improving economy and previously uninsured gaining … Read more

For the most part, tests that are supposed to help clinicians decide which personalized drugs are appropriate for a given patient haven’t lived up to their billing, according to a new study from the Tufts Center for the Study of Drug Development at Tufts University School of Medicine.   Joshua Cohen, PhD, and colleagues reviewed … Read more

An early managed care idea that the marketplace once rejected is now being embraced by employers and offered by health plans In the 2011 movie Moneyball, the general manager of the Oakland A’s is portrayed as one of the smartest executives in baseball. A former player and first-round draft choice, GM Billy Beane pores over … Read more

Many insurers may not consider insomnia a serious health problem, but it costs employers a bundle in lowered productivity Martin Sipkoff Inadequate identification and treatment of insomnia has serious medical and public health implications, resulting in impaired productivity, diminished quality of life, and potentially life-threatening comorbidities. According to several studies, including a review this year … Read more

The top five generic drugs released over the past three years reduced pharmacy spending for Caremark by 4.8 percent in 2004, compared with what it would have spent on the branded drugs. This reduction is largely based on the timing of the release of generic products to the market. As more highly prescribed drugs lose … Read more

An affiliation between the parent of Blues companies in four Pacific Northwest states and the operator of Blues plans in Illinois and Texas will create the nation’s largest not-for-profit insurer. The Regence Group, as the new combined company will be called, will boast 10 million lives. The deal is not a full-blown merger of assets, … Read more

Visits are going up and most cases seen in the ED are legitimate. What’s a payer to do? John Carroll Contributing Editor Poring over the latest data from the Centers for Disease Control and Prevention, leaders of the American College of Emergency Physicians recently pointed to a 10 percent rise in the number of people … Read more

The Next Frontier: Patient Engagement 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 Reformed UCR Calculations Not Without Problems Ingenix was criticized for understating UCR rates, but newer formulas also enrage members who get big balance bills … Read more

Separating Fact From Fiction: Are ACOs the Answer? Submitted by gknorman on Wed, 2012-12-19 22:29 Gordon K. Norman, MD, MBA It’s hard to open any health-related publication these days and not find stories about accountable care organizations (ACOs). Commentary ranges from extolling ACOs as our last, best hope for achieving high-value care in the U.S., … Read more

Technology that allows you to zap prescriptions to pharmacies instantly is already being used by some doctors. Are you willing to discard your pen and pad for a computer that can send electronic prescriptions? No longer does Mike Schoenleber, M.D., handwrite every prescription. Nearly all of the prescriptions that the Minneapolis-based family physician authorizes, he … Read more

Can commercial health plans learn from Medicare Advantage Prescription Drug Plans that have four or more formulary levels? A three-tier formulary has become a standard in commercial drug plans in recent years. But the new Medicare Part D market has resulted in a vast — critics say bewildering — array of benefit and tiering options. … Read more

Despite popular belief, managed care is not fraud-proof. Every $1 that health plans spend to set up special investigation units could result in $7 recovered. When the 1,392-count indictment against Richard G. Paolino, DO, was first read in August 2001, the huge press conference featured a host of Bucks County, Pa., district attorneys, municipal health … Read more

Sharing can be a fantastic thing ? We’re told it’s fantastic for the environment by cutting out waste and naturally ingestion; we still encourage it inside our kids because of their ethical growth; we all find it found in advertisements, when we think about it because a locale activity we receive a warm and fuzzy … Read more

Deciding to seek NCQA accreditation sets an HMO up for lots of preparatory work. Make sure the effort is well spent. Deciding to seek NCQA accreditation sets an HMO up for lots of preparatory work. Make sure the effort is well spent. If you’re at a health plan preparing for NCQA accreditation, there are some … Read more

While there has been much discussion about the need to reduce medical errors, little attention has been given to how health insurers can help. Patient safety and medical errors have become the focus of increasing attention from the public, policymakers, and accreditation agencies. While most of the epidemiology and interventions that have been developed are … Read more

3 Success Stories A federal report last fall showed that some 180,000 patients die every year from adverse events in hospitals. Alarmingly, the report, Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, by the federal Department of Health and Human Services’ Office of Inspector General, also showed that 44 percent of events that harm … Read more

Private insurers, take a bow. A recent study suggests that your mechanisms for utilization review and management are working to control health care spending better than Medicare, and that the differences are sharply defined. The study, in the December Health Affairs, is a follow-up to a highly publicized 2009 New Yorker article by Atul Gawande, … Read more

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

Most Medicare beneficiaries currently enrolled in prescription drug plans will not see a significant change in premiums in 2010, but the Centers for Medicare & Medicaid Services says some may need to take steps to ensure that they continue to have coverage when open enrollment begins later this year. Jonathan Blum, acting director of CMS’s … Read more

Soaring malpractice insurance rates are thinning out provider ranks in at least a dozen states. Could access problems pose issues for HMOs in those areas? When Donna Baver Rovito, a former broadcast journalist and wife of a general surgeon, agreed to become legislative chair of the Pennsylvania Medical Society Alliance, she never thought she’d use … Read more

Health care executives express relief Andy Slavitt, head of the Centers for Medicare and Medicaid Services (CMS), has announced that the agency “has the opportunity” to sunset the meaningful use program in 2016. “Programs designed to improve often distract,” Salvitt said in a public statement. “Done poorly, measures are divorced from how physicians practice and … Read more

Replicons are sections of viral genome which may replicate their Own, in addition to their cellular chromosome. The brand new Zika replicon system has some of those enzymes giving the virus its own particular structure. As a result of the, the modified Zika virus is no more contagious, lowering the security hazard involved with coping … Read more

The passing of this Medicare Accessibility and CHIP Reauthorization Act of 2015inch (MACRA), also applying regulations in 2016,” two dedicated to physician Medicare settlement with the eye on incentivizing caliber and expenditure economies. From the procedure, nevertheless, Congress along with also the facilities for Medicare & Medicaid companies have generated an intriguing juncture from the … Read more

Pay for Performance approaches are adopted as a way to induce improvements in the standard of healthcare supply. Past studies assessing the effect of these apps are tied to the range of health effects or of health care ailments believed. Within this paperwe measure the potency of a Pay for Performance program on the grounds … Read more

HMO premiums are lower than indemnity costs because members tend to be healthier, says a study by the National Bureau of Economic Research …. The AMA says the average physician’s income dropped in 1998, for the first time in five years, by $2,200…. A sustained HbA1c reduction in diabetic patients produces significant cost savings in just … Read more

The AMA capped a less-than-harmonious convention by selecting its board chairman, Thomas R. Reardon, M.D., as its 1999 president. Reardon turned away a challenge from former Chairman Raymond Scalettar, M.D., in the AMA’s first contested presidential election in five years. Reardon and other AMA leaders were pounded at last month’s meeting in Chicago, where member … Read more

Name Last modified Size Description Parent Directory – 0001/ 12-Jul-2009 20:06 – 0002/ 08-May-2008 03:48 – 0003/ 08-May-2008 03:48 – 0004/ 08-May-2008 03:48 – 0005/ 08-May-2008 03:48 – 0006/ 08-May-2008 03:48 – 0007/ 08-May-2008 03:48 – 0008/ 08-May-2008 03:48 – 0009/ 08-May-2008 03:48 – 0010/ 08-May-2008 03:48 – 0011/ 08-May-2008 03:48 – 0012/ 08-May-2008 03:48 … Read more

BY JOHN LA PUMA, M.D. Last year, 35 states tried to control managed care by passing more than 50 bills ranging from maternal length of stay to grievance procedures to continuity of care. This year, proposed laws about breast cancer surgery and experimental treatment are on the docket. Congress will again get into the act, … Read more

They are bigger than ever. Specialty pharmacy drugs have made their bargaining power more important than ever. Do the P and B in PBM stand for power broker? When Express Scripts announced last December that it had negotiated a discount with AbbVie for Viekira Pak, the company’s hepatitis C drug, it caught the health care … Read more

Medicaid plans in some states will expand, putting pressure on plans’ primary care networks 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 adults under age 65 who were not pregnant … Read more

“Biosimilars Such as ABRILADA represent a chance to assist in improving access to major treatment choices for patients coping with chronic, and frequently painful, inflammatory illnesses,” explained Richard Blackburn, worldwide President, Pfizer hepatitis and hepatitis. “Our present portfolio of approved biosimilar products is among the broadest in the business and we have been pleased to … Read more

Molina Healthcare of Michigan leans on education in effort to improve care for black men Frank Diamond 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 … Read more

California Consumer Health Scope www.healthscope.org Developer: Pacific Business Group on Health, San Francisco, regional employer health coalition Goal: Provide comparative data on health plans and hospitals, as well as general health care information, to consumers Strategy: Establish World Wide Web site, use employee newsletters to build awareness of site To encourage California consumers to think about quality as … Read more

Social determinants of health have been edging into the health care discussion for decades, but in the last few years payers and providers have been plowing millions into the once-marginal idea. And now SDOH has spawned a new group of specialized vendors selling software platforms that connect providers and patients with social service providers and … Read more

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

Adverse drug events and low adherence to medication regimens are two concerns addressed by the newest electronic prescribing tools that will be implemented by the Centers for Medicare & Medicaid Services (CMS) for Medicare Part D recipients. A third tool relates to formulary and benefit transactions. Back in January 2006, CMS approved standards to help … Read more

Treatment improves physical function in adults with active disease Positive results have been reported from a phase 3 study investigating tofacitinib (Xeljanz, Pfizer) for the treatment of patients with psoriatic arthritis (PsA). The study evaluated the efficacy and safety of tofacitinib 5 mg and 10 mg twice daily (BID) in adults with active PsA who … Read more

Committee sees “virtually no chance” of a positive effect Merck has announced that it will stop its phase 2/3 EPOCH trial of verubecestat, an investigational small-molecule inhibitor of the beta-site amyloid precursor protein-cleaving enzyme 1 (BACE1), in subjects with mild-to-moderate Alzheimer’s disease (AD). Merck is terminating the study after an external data-monitoring committee, which assessed … Read more

There is insufficient evidence that atypical antipsychotics are effective in treating eating disorders, substance abuse, and insomnia — medical conditions that these drugs were not approved to treat — according to a new Rand study. Other off-label conditions do respond, though. Evidence supports the effectiveness of some atypical antipsychotics in reducing symptoms of generalized anxiety … Read more

Physician-hospital organizations are “emerging as a rival to multispecialty group practices” in winning contracts with HMOs, according to a recent report from Minneapolis-based InterStudy Publications. And why do HMOs choose to deal with organized delivery systems such as PHOs and multispecialty group practices rather than just signing up individual physicians? For better cost-efficiency and a … Read more

Growth in health care spending has actually slowed in the last few years, according to a study by CVS/Caremark. In fact, in 2010 it grew more slowly than it had in over 50 years. “Analysts attribute this slow growth to the recession — people continue to tighten their belts and focus on ‘necessities’ even as … Read more

So that since a father of three small kids, ” I hear daily from teachers and parents focused on the outbreak utilization of electronic cigarette and smoking dependence among kiddies. Combustible smokes cause the overwhelming most tobacco-related illness. When used as planned, they’re accountable for the passing of 1 / 2 all long-term users. Now, … Read more

King v. Burwell: What did Congress mean by “an Exchange established by a State.” If you’re into health care policy and law, tomorrow is your Superbowl, World Series, and World Cup all rolled into one. Oral arguments for King v. Burwell are scheduled to start tomorrow at 10 a.m. As Richard Mark Kirkner explained in our February issue, the case could … Read more

Mark Herzlich, Boston College All American linebacker and now New York Giants rookie, believes that positive thinking played an important part in his successful battle “to beat bone cancer” and return to football. World-renowned cyclist and cancer advocate Lance Armstrong credits not only topnotch medical care but also positive thinking in his overcoming testicular cancer. … Read more

In a strategic move aimed at retaining and recruiting top physicians, Cigna HealthCare of Colorado has dumped capitation. In late February, the insurer began paying most of its physicians in the state on a discounted fee-for-service basis. The move came after Cigna talked with its physicians and found that most didn’t like practicing under capitation. … Read more

CPOE systems, according to data from the Leapfrog Group, do an inconsistent job of shielding patients from serious errors Medication safety and computerized physician order entry for hospital medications are the top priorities in the meaningful-use incentive payments that begin in 2011. These two items are listed as the first and second objectives in the … Read more

Natco Pharma Ltd. has announced the final approval of its abbreviated new drug application filed with the FDA for 30-mg, 45-mg, and 75-mg oseltamivir phosphate oral capsules––a generic version of Genentech’s Tamiflu. Natco and its marketing partner Alvogen, Inc., are the first generic-drug companies to receive this approval. Natco is located in Hyderabad, India, and … Read more

Nearly 60 health plans have signed on as “early adopters” of the care management and health improvement standards newly updated by the National Committee for Quality Assurance. They are part of NCQA’s Quality Plus Program, which allows NCQA-accredited plans to pursue additional distinction in selected areas by meeting tough new standards even before they become … Read more

Definitions of those species as exceptional inside the hominin clade have tended to concentrate on differences in capabilities such as rituals, speech, social media, technological proficiency and cognitive improvement. Now, however, attention was turned into humans’ unique environmental plasticity. We critically review the expanding archaeological and palaeoenvironmental data sets having to do with the Middle–late … Read more

Socioeconomic status doesn’t explain all the discrepancies The average lifespan of African-Americans is significantly shorter than that of white Americans mostly because of heart disease and stroke, which contributed to the loss of more than two million years of life among African-Americans between 1999 and 2010, according to a new scientific statement published in the … Read more

Studies show Eli Lilly’s Taltz achieves higher remission rates than its main competitor but is also marked by slightly more infections. Back in 2003, in just its second installment, this column highlighted upcoming therapies for psoriasis, a relatively common chronic inflammatory skin disease characterized by red scaly plaques that can be accompanied by joint involvement. … Read more

Uncertainty regarding health insurance exchanges is not going away. Changing enrollment deadlines and newly insured populations have brought challenges to payers and providers. Success will require staying competitive on price, network quality, and access. To succeed, a health plan needs new capabilities, such as flexible network management and an unprecedented level of coordination between payers … Read more

First new active ingredient for OTC acne treatment in 30 years The FDA has approved Differin gel 0.1% (adapalene, Galderma Laboratories), a once-daily topical gel for over-the-counter (OTC) treatment of individuals with acne. Differin gel 0.1% is approved for use in people 12 years of age and older. Differin gel 0.1% is the first in … Read more

American Cancer Society disputes study’s methodology   July 21, 2016 The number of new cases of metastatic prostate cancer climbed 72% in the decade from 2004 to 2013, according to a study from Northwestern University. The report considers whether a recent trend of fewer men being screened may be contributing to the rise, whether the … Read more

Case management, utilization management, and quality improvement staff members can play an important part in promoting improved care for patients Insurers can help hospitals improve quality through utilization management, but it would mean reaching out in a unique way. Most payers have employees with counterparts on hospital staffs: Both health plans and hospitals have utilization … Read more

Few examples highlight the differences between the analog and digital worlds as traditional taxi cabs vs. the ride-sharing company Uber. In most cities, hailing a taxi means stepping out to the curb and then hoping a driver stops. You take whatever you get, then waste time paying by cash or credit card. It is just … Read more

How ready are primary care physicians to talk to patients about cost and quality when high-deductible health plans are involved? A national sample of PCPs suggests that they have limited knowledge and are not ready to advise patients about cost and medical budgeting. Of the 528 respondents to the Robert Wood Johnson Clinical Scholars Program … Read more

INFORMATION TECHNOLOGY Harvard Pilgrim Health Care learned the hard way what Oxford Health Plan and others had already found out: HMOs need good information flow. Bob Carlson Contributing Editor 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 … Read more

Portable interactive communications technology promises to influence health behavior as mere postcards and email messages never did. There will be big rewards for the health plans that figure out how to use it well. That ring you hear may be your health plan’s future. Number-crunching aside, health care is really a very intimate business, and … Read more

Expected executive order would expand definition President Trump is expected to issue an executive order today that will make sweeping changes to the country’s system of health insurance coverage and begin the unwinding of the ACA. The action is a result of the inability of GOP members of Congress to begin dismantling Obamacare. Trump has … Read more

Treatment presents substantial risk of illness or injury, agency says   The FDA has announced a proposal to ban electrical stimulation devices (ESDs) used for self-injurious or aggressive behavior because they present an unreasonable and substantial risk to public health that cannot be corrected or eliminated through changes to the labeling. ESDs administer electrical shocks … Read more

We hear that a whole lot about the marvels of genetic testing, and how it is able to revolutionize medicine in order to discover remedies for deadly diseases. A brand new study from the University of Michigan also shows the way that it could waste a half of a billion dollars per year. Researchers at … Read more

Commercial insurers, the employer and individual market, plus Medicare trends, Medicare Advantage, & Medicaid managed care PAYERS Large Employers Push Back on PBMs In 2020, eight companies in the National Drug Purchasing Coalition hope to change how PBMs do business. THE FUTURE OF MANAGED CARE Lab Benefit Managers Seek To Stem The Rising Tide of Genetic … Read more

Pharmacy benefits managers (PBMs) served notice last week that they refuse to be labeled as bad guys because of soaring drug costs. Prime Therapeutics today served notice that it wants to go even further: They’re the good guys. The PBM announced that it held the overall drug spending increase to just 2.5% last year. But every silver … Read more

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Revenue for your Employers’ Liability Insurance industry has diminished within the previous five years as a result of volatile investment yields. Nevertheless, the mandatory character of workers’ compensation insurance can help to curtail some substantial decrease in industry revenue. Industry revenue, that’s the total amount of gross premium income and investment income, is forecast to … Read more

A lot of people infected with HCV don’t have any symptoms of this disorder before kidney damage becomes apparent, which might take a few decades. Many individuals who have chronic HCV infection develop cirrhosis within many decades, which often leads to complications like bleeding, jaundice, fluid accumulation in the gut, liver or bladder cancer. In … Read more

Increased health plan insolvencies have state regulators scrambling to re-engineer oversight tools. Many states are now using risk-based capital models to monitor health plan finances, but as more physician groups assume risk, it is becoming more complicated to prevent health plan insolvencies. The trend has shifted from the indemnity-plan failures of the early ’90s to … Read more

Deeply held, but not evidence-based, concerns about the possible risks of pharmacologic prophylaxis leave many patients at risk for DVT Joseph A. Caprini, MD, MS, FACS, RVT Department of Surgery, Evanston Northwestern Healthcare, Evanston, Ill., and Feinberg School of Medicine, Northwestern University, Chicago, Ill. Thomas M. Hyers, MD, FCCP C.A.R.E. Clinical Research, St. Louis, Mo. … Read more

Emergency department visits rose to a record 136 million in 2011, according to the Centers for Disease Control and Prevention, an increase of 6 million from the 2010 total. The annual visit rate was 44.5 ED visits per 100 persons, the CDC says. The highest number of visits was made by persons between the ages … Read more

It wasn’t long ago that Medicare held a special lure for HMOs, which saw the government’s foray into managed care as a lucrative opportunity. But if a PacifiCare decision last month is any indication, Medicare is no longer the golden egg. The company’s five-year strategic plan calls for aggressive expansion in the commercial market — … Read more

Companies that negotiate for better prices on specialty drugs without the incentive of discounts and rebates. Health care critics often want to eliminate the middleman. “If only we could get rid of…” they say, before they snarl at a PBM or a health insurer with abysmal social-media profiles. Even Atul Gawande sees middlemen as a … Read more

With retail health clinics popping up left and right, the delivery of care is leaving the confines of the physician’s office and heading for shopping plazas and storefronts. Now hospital care is also on the move and changing venues. We are seeing several models for the delivery of hospital care outside the traditional setting. Convenient … Read more

People with behavioral health problems have stretched emergency departments to their limit as the number of inpatient psychiatric beds has decreased. For many patients, the ED is the first place they go. Even people under the care of a mental health professional wind up in EDs because they’re in crisis and their provider’s office is … Read more

Trends for prescription drug coverage will slow down in 2006 to levels that are closer to those of medical coverage, according to the Segal Co., a human resources consultant. “Trend” refers to the increase in health plans’ per capita claims cost as determined by insurance carriers, managed care organizations, and third-party administrators. Trend is affected … Read more

Bruce J. Goldstein, J.D. Mark D. Abruzzo, J.D. Recently there has been an upsurge in the number and frequency of inquiries regarding adverse credentialing decisions — i.e., decisions in which a managed care organization denies a physician’s application to become a part of a panel, or refuses to renew a physician’s contract and kicks him … Read more

The country’s elite cancer hospitals may be facing a less coddled existence. Fox Chase is getting ahead of the game with efforts to reduce readmissions.   It’s on purpose and there’s a lot of history behind it, but the plain fact of the matter is that the rules that other hospitals have to live by … Read more

Companies that negotiate for better prices on specialty drugs without the incentive of discounts and rebates. Health care critics often want to eliminate the middleman. “If only we could get rid of…” they say, before they snarl at a PBM or a health insurer with abysmal social-media profiles. Even Atul Gawande sees middlemen as a … Read more

Employees won’t be abandoned by their companies, whose contributions will continue to rise — somewhat There’s nothing new about private health insurance exchanges. They’ve been a regular part of the insurance scene for years, with a well-developed market among retirees. But this year the private exchange marketplace for active workers has grabbed headlines as some … Read more

Spending for health care per month per enrollee is 9% to 30% lower in Medicare Advantage (MA) than in traditional fee-for-service Medicare, according to Vilsa Curto of Harvard’s T.H. Chan School of Public Health and colleagues from MIT and Stanford University. Their study, scheduled to be published in April 2019 in the American Economic Journal: … Read more

Back in the previous couple of decades, commercially insured patients at healthcare plans with value-based contracts for diabetes, higher cholesterol and HIV drugs had co-pays which have been, normally, 28 per cent lower for anyone medicines in contrast with patients at different plans, as found by a brand new study from the Pharmaceutical Research and … Read more

In 1997, 15.3 million Medicaid beneficiaries were enrolled in managed care, more than five times as many as in 1991. Except for Alaska and Wyoming, all states have undertaken Medicaid managed care programs, and 12 now have more than 75 percent of their Medicaid beneficiaries enrolled in managed care. But so far, only one state … Read more

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

Unhealthy consumers are adopting digital health technology faster than healthy people, according to research conducted by Rock Health, a venture fund that aims to connect health care technology and entrepreneurs. Digital health adoption closely mirrors general technology adoption, and although penetration is still low, the expectation is that its use will rise. Attitudes toward health … Read more

Commercial health plans should pay physicians in Medicare Advantage plans more to provide the sort of services the insurers want patients to utilize, and pay less for services that they don’t want patients to utilize as much, according to a recent study. “If there are services that Medicare or private insurers want to encourage … … Read more

They have symptoms, but that doesn’t mean primary care physicians can pinpoint a physical problem. Yet they do suffer, and are a cost center for insurers and employers. Don’t look now, but someone’s cloned your Aunt Penny. You know Aunt Penny, or Uncle Albert, or Cousin Rita. Pick a name. Every family has one. It’s … Read more

Nationwide, 283 insurers have some form of contract to sponsor a Medicare Advantage or other prepaid group plan. MA plans are set up geographically. That means that 99 percent of beneficiaries have a choice of plans to choose from, according to report by the Kaiser Family Foundation called Strategies for Simplifying the Medicare Advantage Market. … Read more

Open to take care of patients with common cystic fibrosis mutation. Trikafta is known for patients 12 decades and older with cystic fibrosis that have a minumum of a single F508del mutation in the cystic fibrosis transmembrane conductance regulator gene, that is projected to represent 90 percent of their cystic fibrosis population. “In the FDA, … Read more

There’s a lot I don’t understand about the venture tort industry. In the most lucrative example of “tortuosity” to date, some lawyers have struck a rich deal with the tobacco industry. How and why are matters for legal historians. It’s unclear to me just what form of justice this case represents. But this achievement — … Read more

Iowa works a venture exchange with the national government. Their nation is liable for plan direction, customer support, and Medicaid eligibility decision. 59,228 people signed up for health plans throughout the Iowa exchange throughout the open registration period for 2021 coverage. Iowa’s plan direction functions comprise monitoring and selecting the Qualified health programs that provide … Read more

5 Trouble Spots You Could Face In Implementing the ACA With the Affordable Care Act taking effect in just six months, unfinished regulations, obscure reform mandates, and unintended consequences create a potential minefield for payers Michael D. Dalzell A Conversation With Jonathan P. Weiner, DrPH: Information Technology Required A heath data pioneer launches a center … Read more

The chairman of Rx.com has suggested a third form for prescription reimbursement: Internet Retail Pharmacy, or IRP. Joe Rosson says such a category would save money for health plans, pharmacy benefit managers, and self-funded employers, which reimburse online drug sellers on the same basis as retail pharmacies. Third-party payers negotiate separate rates for retail and … Read more

Disorder community. The Seminar provides tactical key-note plenaries, themed paths and dedicated media sessionsand attendees have the opportunity to actually tailor the function to the demands of their daily function. Liftstream Founder & CEO,” Karl Simpson, stated’Liftstream is Again pleased to wait the entire world Orphan Drug Congress to get 2014. The discipline of rare … Read more

Emerging data show impressive results on glycemic control, but what about long-term results, safety, and high maintenance costs? Bariatric surgery’s reputation as a diabetes fighter grows. It produces weight loss that eclipses medication therapy or lifestyle programs, and some experts even say that it can create an immediate reduction in hemoglobin A1c to a point … Read more

The chances of surviving cardiac arrest in the hospital have improved nearly 12 percent in the last decade, possibly because of the introduction of new treatment approaches and guidelines, including therapeutic hypothermia. “Post Cardiac-Arrest Mortality Is Declining: A Study of the U.S. National Inpatient Sample 2001–2009,” which was published in Circulation, adds that the lowered … Read more

In an era when, some argue, much of medical management is being shifted toward the provider, a study shows that nearly half of physician professional societies still do not consider costs when developing guidelines. This comes from a study, “Cost Consideration in the Clinical Guidance Documents of Physician Specialty Societies in the United States,” in … Read more

Frank Diamond Clinician executives at health insurance plans can stop worrying about whether consumers are savvy enough to navigate the changing landscape of coverage and start worrying about how small businesses will fare under the Affordable Care Act. (Well, keep worrying about both because both will continue to be problems.) Let’s just look at small … Read more

Approximately 25 percent of physician organizations pay their doctors on a purely fee-for-service basis, 25 percent pay them on a purely prospective (capitation or some method completely unrelated to productivity) basis, and 50 percent pay the physicians by using blends of retrospective and prospective payment methods, according to a study by researchers in the School … Read more

The national goal is to immunize 90 percent of children under 2 by 2000, yet today the rate is still only about 75 percent. To meet the target, health plans are employing a variety of new techniques. This article is underwritten by an educational grant from SmithKline Beecham Pharmaceuticals Inc. Article also available in PDF … Read more

Biologists seek to correct flaw in how bacterial susceptibility is tested When a patient is prescribed the wrong antibiotic to treat a bacterial infection, it’s not necessarily the physician who is at fault. The current antibiotic assay––standardized in 1961 by the World Health Organization and used worldwide––is potentially flawed. So says University of California–Santa Barbara … Read more

The program is not for everyone, but patients who qualify appear to have superior outcomes and lower costs See accompanying article: Hospital at Home: Compelling Findings, But Replicable in Other Systems? for reactions to hospital at home model A concept that challenges the conventional wisdom that the hospital is the best site of care for acutely ill … Read more

The Rehnquist Court is decidedly pro-states, as are many lower-level judges, but other factors will affect HMO liability and physician bargaining cases. By Michael Levin-Epstein Contributing Editor With the first Monday in October having come and gone, the Supreme Court is back in business. A Supreme Court led by Chief Justice William Rehnquist, that is, … Read more

ndependent 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

charts For the first time in 10 years, the drop in behavioral health coverage, as a percentage of total employer-sponsored health benefits, has leveled off. But the amount of money the typical employer spends on behavioral health benefits continues to decline. For outpatient care, fewer plans are imposing per-visit dollar limits, but more are placing … Read more

For handling diabetes, a disorder affecting 30 million Americans and costing at $245 billion yearly. New recommendations from the American College of Physicians urge less strict blood glucose goals for some people who have diabetes. Other professional classes believe’s a bad idea. It had been like a person had dropped a bucket of water , … Read more

California Gov. Pete Wilson and legislative leaders of both political parties have defined what they want in managed care reform legislation. All agree on the need to expand enrollees’ rights to appeal coverage denials. Rather than endorse specific pending bills or proposals of a managed care reform task force that completed its work earlier this … Read more

To point out to health care decision-makers today that they ought to consider cost as well as clinical efficacy would risk insulting them. The whole managed care revolution–not to mention the magazine you hold in your hands–reflects acknowledgment of the need to spend resources wisely. But a widely noticed article (“Interpreting Cost Analyses of Clinical … Read more

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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

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

The bipartisan attempt to work out an agreement to fix the Centers for Medicare & Medicaid Services physician payment schedule has fallen apart. This means that physician payments will be cut 10.6 percent on July 1 and probably another 5 percent or more on Jan. 1, 2009. “This would be the second time that Congress … Read more

Forget about “publish or perish.” A program developed by Anthem lets young physicians publish to flourish. Anthem’s American Resident Project (ARP) provides an opportunity for a select few up-and-coming doctors (the program calls them fellows) to write one blog post a month on a subject of their choice. In turn, this can lead to a … Read more

The HRA is not a new tool, but it is getting new respect. Often prodded by employers, health plans are increasingly identifying at-risk populations. Humana’s recent announcement that it would begin offering employers a full menu of wellness programming options breaks new ground for the insurer, but at the core of the plan is a … Read more

Most regret the decision to change systems, survey finds The implementation of electronic health record (EHR) systems has put a dent in the bottom line of several major health care organizations, according to a report in Becker’s Hospital Review. The organizations include the University of Texas MD Anderson Cancer Center and Partners HealthCare, the predominant … Read more

In the bad old days, health plans would contract with a limited number of providers, promising them lots of work in return for low prices. Now, a new generation of narrow networks takes a page from the old HMO playbook, adding fresh comparisons on quality that all providers will find hard to ignore. John Carroll … Read more

They can add competition and lower prices, but some see authorized generics as a ploy to fend off competition from true generics. P​rescription medications account for nearly 20% of all health care spending in the United States. As medication costs continue to rise, a little-known class of generic medications called authorized generic drugs may offer … Read more

At a time when the Affordable Care Act is widely reviled and even liberals are lukewarm in their support, Ray E. Drasga, MD, is an outlier. Based partly on his experience at a free clinic in a middle-class town, he says the nation needs a single-payer system, that the ACA doesn’t go nearly far enough … Read more

This article available in full text PDF The last half of the 20th century presented a dramatic increase in new health care technologies and improved health care practices. The results have been largely predictable: People live longer and enjoy healthier lives, but they experience skyrocketing health care expenditures. The relationship between benefits and costs seems clear. … Read more

In case You don’t yet have an organization to give tube-feeding equipment as well as also you or your son or daughter are preparing to move home with a fresh feeding tube, your own hospital discharge planner or case manager can support you. They can provide you with a listing of businesses to pick out … 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 Peter Boland, PhD Phil Polakoff, MD Ted Schwab, MBA Health care industry pundits believe the Patient Protection and Affordable Care Act (PPACA) of 2010 will restructure the way millions of Americans receive … Read more

The General Accounting Office has found that some health care consultants have been advising physicians to do things that conflict with federal laws and that may be unethical. GAO investigators attended and tape-recorded two consultants’ workshops. One told doctors not to report Medicare overpayments; the other told a physician to give preferential treatment to patients … Read more

Frank Diamond Managing Editor Steve Jobs famously staked his claim at the intersection of technology and creativity. Health insurers are looking for the intersection of technology and benefits knowledge, but are not quite sure how to get there. Do you hire information technicians and train them in the ways of health coverage, or do you … Read more

Breaking a nicotine addiction is difficult; any smoker will tell you that. But physicians can lend a hand to the 46 million Americans who just haven’t been able to throw away that last cigarette. “It’s difficult to identify a condition in the United States that presents such a mix of lethality, prevalence and neglect on … Read more

As the use of biomarkers grows, managed care companies will face tough decisions about setting limits Four things that I read recently really struck me as the deadline for “Tomorrow’s Medicine” approached. First, the new recommendations made by the American Society of Clinical Oncology (ASCO) in the 2007 Update of Recommendations for the Use of … Read more

Case management, utilization management, and quality improvement staff members can play an important part in promoting improved care for patients Sherrie Dulworth, RN Tiffanie Lenderman, MBA Insurers can help hospitals improve quality through utilization management, but it would mean reaching out in a unique way. Most payers have employees with counterparts on hospital staffs: Both … Read more

As of Jan. 1, 1998, fewer than one third of HMOs’ operating margins were in the black. Despite having to face heavier competition, the more profitable HMOs tend to be in metropolitan markets, where the average operating margin is better than twice that of HMOs in small markets. Administrative expenses are similar regardless of market … Read more

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 the Heller School of … Read more

At its best, disease management is neither a turf protector for specialists nor a marketing vehicle for drug companies. It’s a common-sense approach to unifying care for a condition, and it depends on primary care physicians. For a moment, imagine health care providers as the members of a big-city orchestra. Primary care physicians, specialists, nurses … Read more

Hospital administrators oversee physician, nursing, and administrative staffs, and usually take the lead in budget preparation and financial reporting. They are important players who usually sit opposite health plan representatives at the negotiating table. The average base salary for hospital administrators rebounded in 2010 and 2011 after being flat for several years, according to Executive Compensation … Read more

MANAGED CARE February 2003. ©MediMedia USA The Republican Mandate Bush has one year to deliver change, as promised. Medicare, prescription drugs, malpractice insurance are all on the table. John Carroll Contributing Editor Within the Beltway, the word has gone out: This is President George W. Bush’s second 100 days. Fresh from being hailed for leading the way … Read more

Who among oncologists has never deciphered against the procedure for prior consent: the actions to find consent to present our very best patient-care efforts, the further paper work to resist denials, time spent teaching medical reviewers why asked therapies are wanted? After I had been a practicing oncologist, the hassles stung me to get his … Read more

Just how much responsibility and cost consumers are willing to carry when it comes to health coverage is the focus of this issue — September 2003. At it happens, 10 years ago — September 1993 — Managed Care looked at the consumer’s role in grading physician performance. Cost borne by the enrollee wasn’t an issue … Read more

The Indiana Senate last month approved a bill that would expand the choice of physicians for nearly 800,000 HMO enrollees. The bill, which passed by a bipartisan 35-15 vote, would allow patients with special needs to choose a specialist as their primary physician, let patients see a physician outside a company’s network in some circumstances, … Read more

Health plans are expanding MTM — once considered a Part D mainstay — to their commercial businesses. Thomas Reinke Results from an ongoing North Carolina medication therapy management program show just how far MTM services have come, plus the value they offer health plans and patients. A five-year-old statewide MTM program for Part D members, … Read more

About 10.9 million Americans under age 65 purchased individual health insurance policies at some point in 2006, but only 7 million were covered by these policies for the twelve months afterwards, according to findings from the Agency for Healthcare Research and Quality. The 3.9 million who had individual policies for part of the year were … Read more

The executive director of the Foundation for Managed Care Pharmacy speaks of the challenge of reining in escalating drug costs. A Conversation with Michael J. Dillon, R.Ph. Michael J. Dillon has been in the front lines of the explosive growth of managed care and its effect on pharmacy over the last two decades. He began … Read more

In 2006, health care spending averaged $7,026 per person. By 2017, that will shoot up to $13,101. Three-alarm warnings about the rise in health care spending have become routine in Washington D.C., yet, they rarely linger past the 24-hour news cycle. When government officials at the Department of Health and Human Services rolled out the … Read more

Make no mistake: Capitation — despite the beating its reputation has taken of late — isn’t out of fashion. In fact, its prevalence is increasing, with 14 percent more physician groups having some involvement in capitation last year than in 1998. But to succeed under capitation, physicians and other providers need a strategy for protecting … Read more

California Physicians Struggling — Problems Ahead for Other States? Michael D. Dalzell Senior Editor Primary-care practices are hurting, with bankruptcies by the week, but California’s problems today won’t necessarily be everyone else’s tomorrow. MANAGED CARE October 1999. ©1999 MediMedia USA CAPITATION Primary-care practices are hurting, with bankruptcies by the week, but California’s problems today won’t necessarily be … Read more

Nearly all (96%) of U.S. hospitals use electronic health records (EHRs), and 85% share clinical data with other hospitals, according to new survey data from the American Hospital Association Information Technology Supplement. The report comes at the start of the annual meeting of the Office of the National Coordinator for Health Information Technology in Washington, … Read more

When this magazine began over 13 years ago, it was dedicated to helping primary care physicians maneuver through the new and confusing maze of managed care. We laid out the choice facing doctors: “Resist the changes brought about by managed care and accept a dwindling, unsatisfying practice, or understand the changes, adapt to them, and … Read more

The Balkan and northern courses are the principle heroin dealing passages connecting Afghanistan to the gigantic business sectors of the Russian League and Western Europe. The Balkan course navigates the Islamic Republic of Iran (frequently by means of Pakistan), Turkey, Greece and Bulgaria across South-East Europe toward the Western European market, with a yearly market … Read more

This physician and his backers are making a $100 million bet that electronic patient records, and widespread access to them through the Internet, are not far away for most practices. Mark Leavitt is well into his third career, that of health care technology executive. The CEO of MedicaLogic Inc., maker of electronic medical record systems, … Read more

Medication Nonadherence: $290 Billion Problem Research from the New England Healthcare Institute has the world rethinking what the next great advance in health care will look like. While many of us are only now beginning to hear the noise about medication nonadherence, health care leaders are already hot on the trail to finding effective ways … Read more

Uncertainty regarding health insurance exchanges is not going away. Changing enrollment deadlines and newly insured populations have brought challenges to payers and providers. Success will require staying competitive on price, network quality, and access. To succeed, a health plan needs new capabilities, such as flexible network management and an unprecedented level of coordination between payers … Read more

Feb. 16 into the American Medical Association simplifying its position the opioid epidemic isn’t eventually driven by prescribed opioids, but alternatively heroin and fentanyl that’s clinically created and got. The AMA delivered a letter June 16 into Deborah Dowell, MD, the CDC’s chief clinical officer at some moment, which said that the U.S.”no further comes … Read more

CONTRIBUTING VOICES Standing Ovation! “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 … Read more

Name Last modified Size Description Parent Directory 26-Jul-2000 21:05 – 9808.washington_thom..> 29-May-2000 11:54 2k 9808.washington_tele..> 29-May-2000 11:54 1k 9808.washington_take..> 29-May-2000 11:54 2k 9808.washington_some..> 29-May-2000 11:54 1k 9808.washington_medp..> 29-May-2000 11:54 2k 9808.washington_gord..> 29-May-2000 11:54 1k 9808.washington_desp..> 29-May-2000 11:54 3k 9808.truce_gatechart..> 06-Jul-1999 09:06 16k 9808.truce.shtml 29-May-2000 11:53 24k 9808.states_texas.shtml 29-May-2000 11:53 2k 9808.states_statesde..> 29-May-2000 11:53 3k 9808.states_kentucky..> … Read more

Managed care decision makers have a powerful tool that affects patient compliance with antihypertensive medications — the copayment level. This setting has associated clinical and economic consequences for the health plan. Researchers at the Hawaii Medical Service Association found that copayment level, independent of other determinants, was a strong predictor of compliance with antihypertensive medications, … Read more

While local governments ponder just what course to take, health plans prepare to grab as much market share as possible Just days after the nation handed the Obama administration another four-year lease on the White House, regulators at the Department of Health and Human Services rolled out an important new set of rules to govern … Read more

John Marcille Spring fever must have settled in early around here. You may notice two baseball references in our magazine and another in our online blog. The thought of baseball can warm the heart on a cold, snowy day. The blog item refers to a new forum where clinical executives can gather, kind of like … Read more

Diabetes Intervention: Achieving Tight Glycemic Control Through Combination Therapy The alarmingly rapid increase in prevalence of type 2 diabetes has profound implications for morbidity, mortality, and economic outcomes. Health plans that adopt aggressive approaches to treatment will reap substantial clinical and financial benefits. The articles in this supplement, which derive from the proceedings of the … Read more

Type Title Name Story The Incremental Value of Medical Nutrition Therapy in Weight Management webadmin Story Tougher CMS Readmissions Rules Afflict Hospitals at a Bad Time webadmin Story Employers, Others Not Sold On New Anti-Obesity Drugs webadmin Blog entry Reports of the Death of Disease Management Are Greatly Exaggerated Al Lewis Story Pushback on Zaltrap’s … Read more

The Six Million Dollar Man had superhuman eyesight, but insurers won’t have to pay that much for this treatment Thomas Morrow, MD I have highlighted science fiction movies and television shows in the past because so many advances in medicine were predicted by Hollywood. One of my favorites as a new physician was The Six … Read more

Even today, studies show, only half of treatments are truly based on evidence. Here’s an organization looking to better that share, and it may behoove health plans to help. Does Joe V. Selby, MD, MPH, have the toughest job in health care? The evidence is fairly compelling. As executive director of the Patient-Centered Outcomes Research … Read more

Do Out-of-Pocket Payments Put Preventive Care on Hold? Studies by Cigna and Humana challenge some long-held assumptions about high-deductible plans John Carroll Go Carefully When Measuring Quality Gauging and rewarding good work in health care is a noble goal with potentially negative consequences Martin Sipkoff Pay for Performance in Pharmacy Is More Theory Than Reality … Read more

The Interim Federal Health Program The IFHP was pioneered in 1957 to give healthcare benefits to susceptible groups that aren’t otherwise entitled to coverage under provincial insurance plan, and that can’t submit a claim through private medical insuranceplan. Medical care policy provided below the IFHP has been considerably diminished, leading to reduced usage of emergency … Read more

A respected young physician appeared on Oprah earlier this year to offer some common-sense advice about preventive medicine. But the advice wasn’t called disease prevention or health promotion. It wasn’t couched in health plan terms of coverage, copayments, primary providers, or capitation. It barely mentioned the “health care system.” No words about moral responsibility, either. … Read more

They want to make it impossible for insurers to change provider networks after the enrollment period Richard Mark Kirkner More people are signing up for Medicare Advantage (MA) plans at the same time Medicare is pulling back its subsidy from these plans. So as cost-control pressures build on the commercial insurers that provide nearly 400 … Read more

Are clinical duties holding you back from a bigger paycheck? If you’re a group practice medical director, maybe so. A Tampa, Fla., executive group says group-practice medical directors who focus full time on policy issues pull down $30,000 more in a year than do medical directors who retain some clinical duties. Part of the reason … Read more

Escitalopram patients in a Florida Medicaid population had better treatment persistence and lower total health care costs than patients prescribed citalopram Eric Q. Wu, PhD Managing principal, the Analysis Group, Inc. Rym Ben-Hamadi, MSc Manager, the Analysis Group, Inc. Mei Lu, MS Associate, the Analysis Group, Inc. Nicolas Beaulieu, MA Associate, the Analysis Group, Inc. … Read more

The regimens can be complex. PBMs use education, outreach, split fills, and other techniques to help with adherence. Oral chemotherapy drugs have transformed cancer care. Agents such as imatinib (Gleevec) opened the door to long-term remission in chronic myelogenous leukemia (CML). Since then, other oral therapies have improved disease progression and survival in many different … Read more

Anthem is purchasing rival Cigna to get $ 4-8 billion in a deal that could create the country’s biggest health insurance by registration, covering roughly 5 3 million U.S patients. In Only 3 weeks, you start with Aetna’s $ 3-5 billion bid to Humana Inc.. About July 3, that the landscape of U.S. medical care … Read more

One in three Americans is Blending supplements with Prescription medicines, in accordance with fresh research and also the danger of potential interactions between medications and supplements is very important.In this nationwide representative sample of adults, 34.3 per cent reported with supplements and medications together. Adults identified as having a condition were 2.5 times more prone … Read more

Physicians’ well known reluctance to invest in office computer hardware and software is costing health plans money. How to get the docs’ attention? Now is the time for health plans to encourage hospitals, physician groups, and other providers to embrace electronic transactions. Only forceful action by plans can assure that the health industry will achieve … Read more

With Weight Management, One Thing Leads to Another John Muir, the famous naturalist, wrote: “When one tugs at a single thing in nature, he finds it attached to the rest of the world.”  It’s a concept that’s long overdue but now fully ensconced in the field of population health management.  Employee health management (EHM) practitioners, … Read more

He started blogging to get information out to physicians; now he believes that patients too will benefit greatly from e-mail, blogs, tweets, and the like A technology-savvy physician says YouTube and Twitter have the potential to improve patient-physician relationships — and to sharpen health care’s focus on wellness and prevention. When Ted Eytan, MD, began … Read more

The public wants it. Presidential candidates are talking about it. Will Congress make it happen? When Turing Pharmaceuticals raised the price of its toxoplasmosis drug, Daraprim, from $13.50 to $750 a pill, it captured the attention of policymakers in Washington that drug pricing was out of control. Now leaders in Congress are holding hearings to … Read more

“Since the pioneer in mobile remedy, we’re dedicated to continued to attract its own possible capacity to patients using various types of ailments,” explained Mert Aktar,” Vice President of Corporate Development and Strategy in Kite. “We are eager to associate with Oxford BioTherapeutics to greatly simply help hasten the particular research by determining new aims … Read more

Everyone wants to cut medical office costs these days, but not everyone stops to consider the money they may be squandering through poorly managed office dictation. “Every payday most of us have overtime,” says Lee Johnson, head of the transcription department for a large Houston group practice, “yet almost every week we also have to … Read more

Type Title Name Story What Works Best for Patients? PCORI Hopes to Provide Answers webadmin Blog entry Separating Fact From Fiction: Are ACOs the Answer? gknorman Story Higher Copayments and Deductibles Delay Medical Care, A Common Problem for Americans webadmin Story Blues Plan Helps Practices Get Up to Speed for PCMHs webadmin Story Commonwealth Fund sings … Read more

Escalating premiums, changing attitudes play a role in employers’ decision to take on the same thing that burned many physicians: financial risk. Sharon Baker Rapidly rising health care costs, along with the desire to gain more flexibility and control over their health plan offer ings, are leading more companies to self-fund their HMO plans. Although … Read more

FDA Accepts Application for Remicade Biosimilar If approved, the product would be marketed by Merck   The FDA has accepted for review a biologics license application (BLA) for SB2 (Samsung Bioepis Co.), a biosimilar candidate referencing Remicade (infliximab, Janssen), for the treatment of rheumatoid arthritis (RA), Crohn’s disease, ulcerative colitis, ankylosing spondylitis, psoriatic arthritis, and … Read more

Staff physicians of all specialties had average total cash compensation of $156,800 last year, up 2.9 percent from 1995, according to a survey of 124 hospitals and other organizations by William M. Mercer Inc. Twenty-seven percent of respondents did not raise physicians’ salaries in 1996, yet in organizations that responded both years, the average increase … Read more

As the accuracy of torso strap, electrode-based HR tracks was validated, the truth of all wrist-worn, optically based HR tracks is unclear. Assessment of their tracks’ accuracy is crucial for those using these to direct their physiological exercise and also for physicians to whom those individuals report HR readings. The target of this analysis was … Read more

Frank Diamond Senior Editor When it selected the person who would become only the fourth CEO in Kaiser Permanente’s history, it may have seemed that the health plan reached beyond its own culture. George C. Halvorson, after all, is not a homegrown Kaiser product and, unlike David M. Lawrence, MD, the man he replaces, he … Read more

A jump in sales of cholesterol-reducing drugs could accompany the National Cholesterol Education Program’s new practice guidelines on management of hypercholesterolemia — an expense that health plans are likely to pass on to subscribers. The NCEP calls for more aggressive LDL-lowering treatment, setting targets that it says could reduce short-term risk of heart disease by … Read more

Underserved patients haven’t benefitted, researchers conclude The 340B Drug Pricing Program, a 25-year-old discount plan aimed at boosting resources for hospitals treating low-income patients, has not delivered on its promise to enhance care for the needy, according to research from Harvard Medical School and the NYU School of Medicine. The federal program was designed to … Read more

Schisms between HMOs and physicians in two states: In North Carolina, Blue Cross and Blue Shield’s Personal Plan HMO severed relations with MedPartners primary care doctors Oct. 13. The Blues rejected MedPartners’ “demand” for a payment hike of up to 30 percent, while MedPartners blasted the insurer’s “decision to negotiate … through the media.” In … Read more

Health reform means that much of what health insurance plans did is being taken on by providers. An obvious example is the Choosing Wisely campaign, an effort by physician professional organizations to cut down on overtreatment and overtesting. The Affordable Care Act shifts a lot of the responsibility and financial risk onto providers, and some … Read more

Not much will change in Medicare Advantage this year and that’s news, given some of the dire forecasts leveled about the program. “Despite reductions in payments enacted in the ACA [Affordable Care Act], and concerns about the effects of these reductions for plans and beneficiaries, the Medicare Advantage marketplace remains robust in 2013, with little … Read more

Extremely premature infants stand a much better chance of surviving than they did 15 years ago thanks mostly to advances in respiratory technology, according to a study in the New England Journal of Medicine. That’s good news, but there’s still much more work to be done because 1 out of 4 of these tiny patients die … Read more

A development in the catheterization lab involves using a flexible catheter tip to provide 360 degrees of motion Nearly everyone reading this column has used a joystick remote control to play a video game. Weaving a player through a dangerous maze of obstacles and around corners seeking to damage or destroy the enemy in an … Read more

Information technology companies are salivating at the prospect of tens of billions of dollars’ worth of business, now that the Health Insurance Portability and Accountability Act (HIPAA) privacy rules have taken effect. And for all the whining about HIPAA from providers and payers, there are reports that a growing share of them are beginning to … Read more

The number of adults ages 20 to 44 prescribed attention deficit hyperactivity disorder medications increased about 140 percent from 2000 to 2005. This was even faster growth than the 82 percent reported for children (everyone younger than 20). The analysis confirms earlier data from Medco Health Solutions, which last year released data that showed that … Read more

AHIP, AMA, MGMA and others offer recommendations on just how to improve the process. Some heavy-hitting health care organizations think that the prior authorization process needs improvement, saying that it “can be burdensome for all involved—health care providers, health plans, and patients. Yet, there is wide variation in medical practice and adherence to evidence-based treatment.” … Read more

Companies that control their health care costs by aggressively managing their benefit programs and making effective use of account-based health plans, such as health savings accounts and health reimbursement accounts, will pay an average of 12 percent less in premiums this year than will less aggressive companies, according to the 2009 Towers Perrin Health Care … Read more

This tool includes a document library where applicants store the forms needed to show that they are worthy of accreditation. Tony Berberabe Associate Editor “You must undergo accreditation.” In the past, those words might have made even the most stalwart health care executive quake, and to a certain extent, they still do. But the National … Read more

Health plan enrollment has been relatively stable for the last five years, with one exception — the participation of covered workers in high- deductible health plans with a savings option (HDHP/SO) has grown from 8 percent in 2009 to 13 percent in 2010, according to the Kaiser Family Foundation and Health Research & Educational Trust. … Read more

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

224,000,000 dollars spent by Medicare to hospitalize beneficiaries who quit 1 of 6 HMOs within three months of their admissions 20,000,000 dollars Medicare would have paid to those six HMOs (now under federal investigation) if the same patients had remained members 710 physicians — out of 710 — told Western Journal of Medicine researchers they would hesitate to … Read more

MANAGED CARE October 2003. ©MediMedia USA TOMORROW’S MEDICINE Treating severe vesicoureteral reflux involved complicated, expensive surgery. Now an injectable agent that forms a valve can lead to normal urination. Thomas Morrow, MD Vesicoureteral reflux (VUR) is probably not at the top of the list of concerns for most managed care executives, but it is of great importance … Read more

More employers and health coalitions are using their market power to promote quality and lower costs–and that’s good business, says a fresh Agency for Health Care Policy and Research report. The report, “Theory and Reality of Value-Based Purchasing: Lessons from the Pioneers,” says the pioneers are employers that use their purchasing power to collect data … Read more

A widely available but underused molecular genetic blood test has proved to be accurate over 98% of the time and costs less than $400 With the development of molecular diagnostics evolving at a rapid pace, it can be challenging for third-party payers to keep abreast of best practices in genetic testing and to develop smart … Read more

For the past 20 years, the VA has labored at one of the most advanced electronic medical records in the country – and is giving the technology away. Private vendors object that it relies on outdated software. It’s “snow bird” season in Phoenix. They’re easy to spot, driving in cars displaying plates from cold Midwestern … Read more

PBMs: New Power and Influence They are bigger than ever. Specialty pharmacy drugs have made their bargaining power more important than ever. Do the P and B in PBM stand for power broker? PBMs Just Say No to Some Drugs–But Not to Others Formulary exclusions give them added clout with drug companies in this day … Read more

Hispanics will be the most significant minority group within the united states. They bring to the market, cultural diversity, cultural diversity, and wellness of the country. Evaluating their overall health condition and wellness demands is essential to educate health plan formulation and application execution. For the conclusion, we ran a scoping overview of this literature … Read more

Tapping into local foundations’ expertise and knowledge is one way managed care can start to reinvent itself. Bob Carlson Contributing Editor We’ve enjoyed our relationship with managed care, and we’ve learned a lot from what they’re doing, and hopefully they’ve learned from some of our work,” says Robert K. Ross, MD, president and CEO of … Read more

CDHPs and catastrophic insurance plans can save consumers money, but do high deductibles add to overall costs down the line? The rising cost of health insurance premiums for employers — up 131 percent in the last decade, to an average $13,375 per year for family coverage, according to the Kaiser Family Foundation — has led to … Read more

Americans made 787 million trips to the doctor in 1997, more than half of which were visits to primary care physicians. According to the National Center for Health Statistics, about 15 percent of all outpatient visits to physicians involved a referral from another physician or a health plan. Only 1 in 10 required authorization, and … Read more

To compare effects of diabetes mellitus patients commencing treatment with FDC vs. people that have loose-dose combination or measure therapy in a managed care population. A retrospective asserts database investigation. Treatment-naive T2DM patients that were enrolled in a health plan throughout 2006-2009 were also studied. Exotic patients were delegated into FDC, LDC, or s t … Read more

This is true of caller-id”spoofing,” a hightech manipulation of this Caller ID feature which enables the scammer to conceal their identity by which makes the telephone seem to be the the hospital. This scam was targeting hospital patients nationally. Is obstructing a phonenumber exactly the exact same as spoofing? Spoofing isn’t the identical as blocking … Read more

This nationally recognized expert who has long been frustrated by the pace of change says that — ready or not — health care reform is finally on the way Michael L. Millenson is frustrated at the pace of change in reducing medical errors and adopting evidence-based care. Ten years after writing the ground-breaking book, Demanding Medical … Read more

The digital Revolution will be here now. It has attracted us smart-phones, social networking, and also the sharing market, also it has ultimately changed the way in which we live, work, and drama with. Companies Are aggressively using smart technology to make Services and products which are earning goods and services more economical and more … Read more

King v. Burwell: What did Congress mean by “an Exchange established by a State.” If you’re into health care policy and law, tomorrow is your Superbowl, World Series, and World Cup all rolled into one. Oral arguments for King v. Burwell(link is external) are scheduled to start tomorrow at 10 a.m. As Richard Mark Kirkner explained in our February issue, … Read more

UnitedHealthcare’s VP for oncology says it will take time to come to grips with the cost of chemotherapy, but we have to start now It has been a little more than a year since UnitedHealthcare launched a pilot program to test a bundled payment model for oncologists, and the insurer and its five pilot sites … Read more

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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 Wages for different Occupations within the General Public Health Field Also Can Vary considerably. There are several diverse areas within public health and fitness, however the wages ranges listed here will be exactly what you may get once you graduate using an MPH and also have functioned around annually. Careers in health care management … Read more

One of the buzz terms often heard in discussions of improving the health care system is “patient engagement.” But what does it mean? The definition changes, says a new analysis in the Journal of Participatory Medicine. “Despite the widespread use of the term ‘patient engagement,’ our study showed significant variations in its conceptualization, testifying that … Read more

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

Use of aggressive techniques to encourage patient adherence saves and improves lives and controls costs Martin Sipkoff Contributing Editor Former surgeon general C. Everett Koop, MD, famously said “Drugs don’t work in patients who don’t take them.” This is exceptionally true, with potentially terrible consequences, of specialty medications. “Medication adherence is particularly important for people … Read more

Although 3 out of 4 primary care physicians support the use of financial rewards as an incentive for better medical care, the majority would rather not make quality assessments readily available to the public, according to a recent survey by the University of Chicago Medical Center. Physicians in the survey view public reporting as potentially … Read more

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

A Diabetes Drug For People Without Diabetes Dapagliflozin, which is already used to treat type-2 diabetes (T2D) and prevent development of heart failure, can also be used to treat pre-existing heart failure—even in patients without T2D, new research shows. The study was presented at the annual meeting of the European Association for the Study of … Read more

At the time of February 2021, 1 2 says never have embraced the Affordable Care Act supply to expand Medicaid to adults who have incomes throughout 138 percent of poverty. Huge numbers of men and women in those countries remain without a reasonable policy option. Even the American Rescue plan-act of 2021 supports non-expansion nations … Read more

Back in the heyday of managed care, primary care physicians were poised to occupy the central role in health care delivery. Over the last half-decade, that has changed. A survey by Merritt, Hawkins, & Associates, a search-and-consulting company, suggests that physicians consider themselves to be busy but poorly paid, although maybe everyone who collects a … Read more

Medical directors at health plans saw a 7.2 percent rise in mean direct compensation from 2003 to 2005. Average pay increases for physician executives in recent surveys ranged from 5 percent to 7 percent. What is surprising is that when compared to the larger group of all physician executives surveyed, medical directors at health plans … Read more

EMS reacts to a house to get a seven-year-old man using a cough and trouble breathing. This incident began two weeks past and was along with a runny nose without the other signs and symptoms. His mum was handling him by albuterol by way of a nebulizer, however he’s got become more short of breath. … Read more

Possible link to long wait times for VA care Military veterans are more likely to report delays in seeking necessary health care compared with the U.S. general population, according to a study in the Journal of Public Health Management and Practice. Such self-reported care delays may be related to having Veterans Administration (VA) health coverage—and to … Read more

One hospital system accepted the general wisdom a few years ago by acquiring physician practices. Now it bucks the new wisdom by holding on to them. Bart Dawson doesn’t flinch at adversity. In 1994 at the height of a nationwide hospital feeding frenzy to acquire primary care practices, Dawson, then 52, a lawyer and practice … Read more

Between 50,000 to 100,000 deaths occur each year while millions of dollars are wasted on caring for conditions that could have been avoided, according to a report by the Centers for Disease Control and Prevention, the first in a series that will look at preventive care. Health insurers offer a benchmark for how prevention should … Read more

Having driven generic utilization about as far as possible, plan sponsors are turning to a method of controlling drug costs that had all but disappeared. Aggressive contracting is driving this trend, but that may soon yield to evidence-based evaluation.   Michael D. Dalzell Senior Contributing Editor inShare Tweet Widget (link is external) If this decade … Read more

High-profile activities are nothing new at New Mexico’s Lovelace Health Systems. The multifaceted organization, which grew out of a Mayo Clinic-style group practice founded in 1922, developed and performed the clinical examinations given the first Americans in space, the Mercury astronauts. But Lovelace’s first forays into disease management were more a coalescing of parts than … Read more

John A. Marcille What would this country be if we didn’t have something to complain about? After all, America was born out of a difference of opinion, so it stands to reason that finding negativity in something and beating it to death has become something of a national sport. Just look at the way the … Read more

Varying drug prices by indication could be an important value-based strategy in oncology, where multiple indications are becoming the rule. But will administrative costs offset any benefit? And legal and regulatory obstacles could get in the way. Cancer treatment is advancing rapidly but at eye-popping prices. Six-figure oncology drugs are increasingly common, necessitating new approaches … Read more

Alan T. Wright, MD: He Wants AdvancePCS to Manage More Than Drugs The CMO of the nation’s largest pharmacy benefits manager says that the company’s mission has broadened. One new area of focus: worker productivity. Defined Contribution: Threat… or Fad? Sensing an invasion of their territory, MCOs are jumping into a market forged by a … Read more

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

Opioids have usefulness in constipation therapy, nevertheless they’re frequently over-prescribed, which may possibly be damaging patients. For specific groups of individuals with Endometriosis, such as the older and elderly women who regularly avert triptans or antipsychotic anti inflammatory drugs, psychiatric drugs may be employed for intermittent pain control. Opioids are still to be Utilised in … Read more

Humana and United HealthCare will never make it to the altar. The two companies terminated their merger agreement after a stock swoon dropped the value of the union from $5.3 billion to $3.1 billion.Wall Street got nervous when United announced a $565 million second-quarter loss stemming from a one-time $900 million charge associated with “strategic … Read more

In New Jersey, Horizon’s patient-centered medical home program puts data-savvy nurses in primary care practices to reach out to high-risk patients and forestall costly crises Trying to save money in health care isn’t new to Sandra Siegel, RN. A nurse with 30 years’ experience, she remembers working for a managed care company in the ’90s … Read more

Warning! Physicians, please share this article with your management consultants, CPAs and any other advisers who look over your claims submission, records documentation and contracting activities. Inadvertently, they may be placing you and themselves in serious trouble! The problem stems from the dramatic new fraud rules imposed on providers by the Health Insurance Portability and … Read more

September 2011Is the breast cancer drug Avastin the opening salvo that brings efficacy, toxicity, and costs together? Who will blink first — health plans, providers, regulators, or patients? DIGITAL | HTML TOMORROW’S MEDICINE Injected Device Shown Effective in Reducing Fecal Incontinence For this condition that is largely confined to the Medicare population, a new treatment is now … Read more

Off-label provisions spread Color chart Twenty-eight states mandate some form of insurance coverage for off-label pharmaceutical use, and the trend is accelerating. In 1997, 11 states implemented off-label coverage provisions. Such laws typically forbid coverage denials based on grounds that an indication has not been approved by the Food and Drug Administration.

Many states have laws governing the timeliness of claims payments to physicians, hospitals, and other providers, but few such statutes have any real effect because of lack of enforcement or clarity. A handful of states are toughening their so-called prompt-payment laws, but most of these changes are coming at the expense of insurers. California lawmakers … Read more

The diverse Latino population requires insurers to understand that there is no cookie-cutter answer for successful medication management Martin Sipkoff Diabetes and other chronic diseases disproportionately affect the 15 percent of our population that is Latino. Because health plans play an important role in encouraging patient medication management, several national and regional plans are developing … Read more

Health Reform and the Use of Financial Incentives in Wellness Programs The Affordable Care Act codified the worksite wellness exemption to the federal medical underwriting provisions in the group health plan market. This means companies are allowed to use an “outcomes-based” incentive model that provides financial rewards for those who satisfy a prescribed health standard … Read more

Advances in computer technology have placed us on the threshold of a new way of delivering care that is both economical and incredible Robots and computers have fascinated most of us for decades. I fondly remember programming in Fortran using 88-character punch cards and being amazed at how rapidly a computer could solve equations that … Read more

EDITOR’S FAREWELL MEMO No Change in Mission, But a Changing of the Guard This is my last memo: I am retiring after 17 years as editor. I’ve worked with too many people to be able to thank them individually, but for most of those years I have had Frank Diamond as my managing editor, and … Read more

This is no one-size-fits-all solution, as insurers across the country tailor efforts for specific markets Lola Butcher Even as they hold out great hope for the accountable care movement, the nation’s leading health plans consider the creation of medical home practices to be the first logical step toward higher quality and more cost-effective patient care. … Read more

A growing number of health plans are adding these clinics in retail stores to their networks and are realizing savings Retail health clinics. All the major health plans are adding them to their networks. Busy families are demanding simpler ways to deal with routine health problems, and some of them are turning to the local … Read more

Care transitions around preferences are exposed market points to patients and family health professionals which subscribe to raised risk of illness effects. Nevertheless, maintenance changes for people with health problems, such as stroke, and remain ineffective, leading to unmet patient and health care requirements, higher safety risks, high levels of preventable readmissions, and greater health … Read more

Maine’s health care reformers are on course to deliver a controversial universal care plan. But is the coast clear? In Maine, the state motto is summed up in a single Latin word — dirigo — which in 21st century America translates into a bare-knuckled political proclamation: I lead. So when the newly elected governor of … Read more

U.S. scientists see potential for widespread outbreak A virus similar to the one responsible for severe acute respiratory syndrome (SARS) has been found in Chinese horseshoe bats and may be poised to infect humans without the need for adaptation, potentially setting the stage for a widespread outbreak, according to a study from the University of … Read more

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IQM penis hospitals Utilize quality signs which can be calculated from regular data. The Inpatient Quality Indicators are ascertained by hospital billing data along with also the medical proof data included therein. IQM employs the G-IQIs and also CH-IQIs to map out a hospital’s operation for diverse diseases. The existing edition, 5.2, comprises over 380 … Read more

John A. Marcille There is every reason to think that the growing development of genetic tests and therapies will have a remarkable effect on health care. Who can help but feel a thrill at such possibilities as restoring the body’s ability to create insulin, or preventing Alzheimer’s disease, or identifying people who are most susceptible … Read more

There aren’t enough geriatricians to go around, but judicious use of these specialists can still do a lot for an aged population. As Roy Erickson, MD, chief medical officer at Evercare, and Cheryl Phillips, MD, medical director of Sutter Medical Group, work to recruit physicians for their Medicare managed care populations in the next several … Read more

A group of physicians calling itself the “Terbutaline Strategy Group” has petitioned the U.S. Food and Drug Administration to reverse itself, after the agency mailed a “Dear Colleague” letter warning practitioners about use of terbutaline sulfate for prevention of preterm labor. The doctors worry that the FDA action could remove one of their most effective … Read more

Multiple news outlets are reporting that a letter signed by Representatives Henry Waxman, Frank Pallone Jr., and Diana DeGette was sent last week to the CEO of Gilead asking for justification for the high price set on its new Hepatitis C medication, Sovaldi. (See this story.) The lawmakers also stressed that they expect Gilead to … Read more

The current debate over a single payer system calls to mind the parable of the blind men describing an elephant. Michael S. Victoroff, MD “And Moses said to Pharaoh, ‘Let my people go!’ And Pharaoh said, ‘You don’t seem to understand the implications of a ‘single payer’ system.’” When I was little, there was a … Read more

Joyce R. Ochs MANAGED CARE February 2001. ©MediMedia USA Joyce R. Ochs Business-to-business commerce via the Internet, known as B2B in Internet lingo, has not received the media attention that has made business-to-consumer (B2C) companies such as Amazon.com as familiar as IBM. Yet the dollar volume of B2B transactions on the Internet is expected to be 10 … Read more

Paul Terry’s blog Health Reform and the Use of Financial Incentives in Wellness Programs Submitted by Paul Terry on Mon, 2011-11-07 14:35 Affordable Care Act Financial incentives Health Reform Outcomes based incentives Progress based incentives Wellness The Affordable Care Act codified the worksite wellness exemption to the federal medical underwriting provisions in the group health … Read more

One of the problems deals with uneven coverage among different health insurers. Doctors want more clarity. While the consensus is that telehealth is cresting as the wave of the future—expanding patients’ access to care, addressing the needs of today’s time-pressed, on-demand society—what’s still far from clear is how, or how much, providers will be paid … Read more

Ntegrated care models may boost the type of alliance that is required to take care of complex, hereditary problems such as chronic pain. They’re one of our greatest hopes to get an alternate to the over use of prescription pain killers which has generated so much distress and premature departure. The country is in the … 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

Kaiser Permanente and the federal government believe that they’ve found the path to a national health record system Frank Diamond There’s a little experiment going on in the San Diego area that health plan medical directors and other stakeholders may want to pay close attention to. Kaiser Permanente and the Department of Veterans Affairs have … 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

First systemic treatment with positive phase III results in moderate-to-severe disease Two phase III, placebo-controlled studies evaluating dupilumab (Regeneron Pharmaceuticals/Sanofi) in adults with inadequately controlled moderate-to-severe atopic dermatitis (AD) have met their primary endpoints. In the studies, known as LIBERTY AD SOLO 1 and SOLO 2, treatment with dupilumab as monotherapy significantly improved measures of … Read more

Community Care of North Carolina says it has data on decreased hospital utilization and ER visits Is Community Care of North Carolina a model for the nation? While health plans and providers have developed patient-centered medical homes (PCMHs) in an effort to improve primary care, health plans and health policymakers have tried for years to … Read more

FEATURE Medicaid Fosters Innovations In Treatment of Mental Illness The ‘health home’ is just one of the strategies helping to meet the needs of this vulnerable and costly population The Medicaid program is proving to be an incubator of innovative services and delivery system reforms for people with complex behavioral health conditions. And in a … Read more

Abstract Purpose: To analyze the cost difference between minimally invasive surgery (MIS) and open surgery from a commercial payer perspective for colectomy, ventral hernia repair, thoracic resection (resection of the lung), and hysterectomy. Design: A retrospective claims data analysis was conducted using the 2011 and 2012 Truven Health Analytics MarketScan Commercial Claims and Encounter Database. Study eligibility … Read more

Background The formularies of nearly all managed care organizations (MCOs) and pharmacy benefit managers (PBMs) share the near-total absence of homeopathic drugs. The authors explore the possible use of homeopathic drugs in a managed care setting and make some suggestions for formulary committees’ consideration. The broad research question is whether there is a role for … Read more

Even the ACA drove the uninsured rate inspite of the dearth of Medicare expansion, however, major insurers have abandoned the marketplace. In a few rural places, Florida Blue could be the sole health plan while within this overall game. Also in the mixture: Consumers usually select the lowest-cost plan readily offered. Lately, Florida, sunlight State,” … Read more

A new study reveals that consumers who participate in full-service, stand-alone vision insurance plans are two times as likely to have an annual comprehensive eye examination as consumers that have vision care coverage through their major medical plan (33 percent versus 16 percent). The study, conducted for the National Association of Vision Care Plans (NAVCP), … Read more

Financial security in the face of rising debt for medical school is important when a resident decides on a specialty — and a new study shows just how much a career in primary care is at a disadvantage. Researchers at Dartmouth Medical School developed a financial model that compared net income to expenses, taking into … Read more

Compared to the existing state of affairs, there’s a lot to like in mandatory coverage, but the Massachusetts experiment is a lesson to not expect miracles Inside the Democratic party, it’s axiomatic that health care insurance reform is crucial to unlocking the door at 1600 Pennsylvania Ave. In poll after poll, a majority of voters … Read more

Traceability key if biosimilars are to compete, cut costs Generic versions of small molecule drugs have generated a trillion dollar-plus in savings (link is external), by some accounts. People who care about health care costs are hoping that biosimilars (link is external) might also ratchet down the country’s health care bill by a notch or … Read more

The Many individual insurers have been after Medicare’s lead. Much of the policy attention was on apps like accountable maintenance businesses and bundled obligations; nonetheless, value-based purchasing or Pay for Performance, understood to be providers getting paid back with repayment adjustments up or down based on value metrics, and remains a central section of value … Read more

Is health care a free market? Legislators in Florida and Virginia want it to be, so they are moving to scrap the laws that require health care providers to get state approval before they expand or add services. Meanwhile, hospital interests in several states are fighting to preserve some measure of state control. Known as … Read more

Premera’s method of analyzing the potential benefits of Byetta shows how third-party modeling can pinpoint which members can benefit from easier access — and how plans can determine authentic cost savings John Carroll Contributing Editor John Watkins, RPh, the pharmacy manager in charge of formulary development at Premera Blue Cross, clearly recalls the first reaction … Read more

Makers of this expensive new cystic fibrosis medication manage to sidestep controversy. Health plans may not be as lucky as they weigh cost against value. How is this for shrewd maneuvering? Earlier this summer, Vertex Pharmaceutical received FDA approval for its Orkambi medication for treating people age 12 and older who have a gene mutation … Read more

Managing Editor’s Memo Frank Diamond Back before our first distant amphibious ancestors emerged from the primeval ooze onto a landscape that looked more like the surface of the moon than Mother Earth, say the 1970s, the great spin on public perception seemed to be that diabetes is not so bad as you might think. I … Read more

About 10.9 million Americans under age 65 purchased individual health insurance policies at some point in 2006, but only 7 million were covered by these policies for the twelve months afterwards, according to findings from the Agency for Healthcare Research and Quality. The 3.9 million who had individual policies for part of the year were … Read more

Too Early To Predict PCORI’s Impact The Patient Centered Outcomes Research Institute has only just begun to award grants so it might take some time to determine how effective efforts tied to that money might be, says David B. Nash, MD, MBA, the founding dean of the Jefferson School of Population Health at Thomas Jefferson University … Read more

One of the ethical successes of managed care has been the improvement it has made in people’s access to physicians. A $5 copayment saves lives and enhances the well-being of millions who would never have gone to a doctor in an indemnity or high-deductible environment. However, opening medicine’s doors to a broader population has invoked … Read more

Even the most effective drug is useless if people don’t take it because it’s so expensive. Today’s high prices are pushing more and more patients into nonadherence. It’s a prescription for trouble for us all. If it were an illness, you know there’d be a pill. If it were a data need, Silicon Valley would … Read more

Usually it ill befits a magazine to take issue with its own past issues. But today I might rethink the opening line of the State Initiatives column in the May Managed Care. That column began, “The anti-managed care drive continues at the state level,” then went on to describe legislative efforts in various states to … Read more

Legislators look for a way to help payers and patients cope with the high cost of biologics without destroying the businesses that made these products possible For anyone managing a drug budget, there is one issue that almost always boils up when a discussion turns to the fast-growing costs of biologics: legislation that will do … Read more

Finally, However, some experts say society is going to soon be better served if clinical researchers go more slowly and sensibly. In Its present symptom, gene therapy is still a tasteful concept crudely implemented. That is no indictment — that is just the way it really is for a remarkably complicated technology in its entirety. … Read more

Patient-specific multicellular therapy reduces deaths and hospitalizations Positive results have been announced from a phase 2b trial of ixmyelocel-T (Vericel Corporation) in patients with advanced heart failure due to ischemic dilated cardiomyopathy (DCM). The study met its primary endpoint of demonstrating a reduction in the total number of deaths, cardiovascular hospitalizations, or unplanned outpatient and … Read more

The former speaker of the house strongly favors a free-market overhaul of the system that would change the way consumers behave. Should you worry? ‘Nobody washes a rental car’ – Managed Care‘s Q&A with Newt Gingrich No one has ever called Newt Gingrich feckless. The former speaker of the House of Representatives fell off the … Read more

Value-based agreements between insurers and drugmakers have gotten a lot of attention lately, but device makers, including those that make continuous glucose monitors, are also making deals with insurers that tie payment to how the device performs. Suzanne Winter, vice president of the Americas region for Medtronic, says a value-based agreement with Aetna focuses on … Read more

Steven J. Fox Rachel H. Wilson John W. Jones Jr. Although the final privacy rule in the Health Insurance Portability and Accountability Act (HIPAA) eases some burdens for managed care organizations and providers, it still significantly restricts the use and disclosure of protected health information. Covered entities must prepare to comply by the Aug. 14, … Read more

A summary of ECRI Institute’s Health Technology Forecast Report The CardioFit System consists of an implantable neurostimulator, a sensing lead, and a stimulation lead. According to the manufacturer, device implantation can be performed using local or general anesthesia. A physician implants the neurostimulator under the skin near the clavicle, similar to cardiac pacemaker implantation. The … Read more

A Henry J. Kaiser Family Foundation study indicates large and medium-size employers are slowly moving away from providing retiree health benefits. Those continuing to offer supplemental Medicare coverage employ cost-control strategies, such as charging premiums or using dollar caps, more frequently than in years past. The study also reveals a strong trend toward use of … Read more

Despite anecdotal reports to the contrary, the great majority — 87.6 percent — of physicians have contracts with managed care organizations. A new report from the Center for Studying Health Systems Change says that in fact, 70 percent of physicians had contracts with five or more managed care plans. How does this affect a physician’s … Read more

A year and a half in the making, the U.S. Agency for Health Care Policy and Research’s National Guidelines Clearinghouse is up and running at http://www.guidelines.gov/. This resource gives users access to thousands of clinical protocols issued by AHCPR, professional organizations, and even some health plans. Proprietary and commercial guidelines, such as those issued by Milliman … Read more

Ustekinumab Demonstrates Clinical Response, Remission in Crohn’s Disease Treatment under official review in U.S., Europe   Treatment with ustekinumab (Stelara, Janssen) induced clinical response and clinical remission in adult patients with moderate-to-severe Crohn’s disease who had previously failed or were intolerant to treatment with one or more anti-tumor necrosis factor (TNF)-alpha therapies, according to phase … Read more

Physicians find men lack interest in seeking medical care if they can’t get coverage for erectile dysfunction. Viagra, the “little blue pill,” started a revolution in 1994, sending men to the doctor’s office who would not ordinarily go. When it comes to seeing their doctor, many men will figure out a way not to. Men … Read more

What Obama and Congress have started, the Supreme Court could finish. If it doesn’t, the Republicans may move to undo the ACA in other ways. The Republican-controlled Congress hadn’t even been in session two days when it landed its first blow in its much-publicized effort to dismantle the ACA. The House passed legislation to redefine … Read more

MANAGED CARE October 2003. ©MediMedia USA Cigna has become the second of eight health plans to reach a settlement with about 600,000 physicians over allegations that the insurers delayed or rejected physicians’ insurance claims for medically necessary treatments. In agreeing to pay $540 million to settle the class-action lawsuit, Cigna follows the lead of Aetna, which came … Read more

Oncology experts offer advice Many cancer patients find themselves in financial distress partly because the costs of cancer-fighting drugs are skyrocketing, according to an editorial in JAMA Oncology. Is it possible to create public policy that will rein in these prices and cut patients’ out-of-pocket costs? Not without significant tradeoffs that could reduce patients’ access to … Read more

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

News & Commentary The incidence of diabetes is rising quickly, according to the Centers for Disease Control and Prevention, but just what’s causing the increase is difficult to determine. The CDC study, published in the agency’s Morbidity and Mortality Weekly Report, shows dramatic increases in diagnosis between 1995 and 2010. “Increasing incidence might be the … Read more

Family and general practitioners would do well to move their practices to Wisconsin, Arkansas, West Virginia, or Kansas. That’s because FPs and GPs in these five states get paid the most for this profession — especially when the cost of living is factored in. Cost of living applies to the average cost of basic necessities … Read more

PTC Therapeutics has announced new data supporting the potential benefit of ataluren in preserving lung function in patients with nonambulatory nonsense-mutation Duchenne muscular dystrophy (nmDMD). The results were based on analyses of lung function data from one of the company’s ongoing open-label extension studies compared with natural history data from a comparable nonambulatory cohort. Ataluren … Read more

“Difficult-to-treat GramNegative pathogens pose a substantial health hazard, especially to the sensitive and vulnerable pediatric patient population having few possibilities for treatment,” said David Nicholson, Chief Research & Development Officer in Allergan. “As immunity climbs one of the GramNegative pathogens which cause these severe ailments, the enlarged label for AVYCAZ supplies a secure and efficient … Read more

Finally, it seems that there is a way to manage patients with multiple chronic conditions properly. Understanding and technology converge. It’s as if that relative — the one who people thought would never be able to hold down a job and who long ago packed his belongings into a 1958 Edsel and sputtered off toward … Read more

When American Healthways posted a collaborative methodology on its Web site, not everyone in the industry applauded. One year ago, Victor Villagra had good reason to believe the disease management industry was on the threshold of embracing a standard method for evaluating just how well DM programs work. Villagra, the former president of the Disease … Read more

Health plans that have resisted inappropriate state mandates might be in a position to bill those states for their cost when policies are sold through an exchange The Department of Health and Human Services won’t decide before the end of this year exactly what “essential services” are to be required for health plans to be … Read more

GOP lawmakers rarely cite Obamacare, and also a GOP-backed challenge into regulations at the Supreme Court does not seem to become a significant threat. Along with long-favored Republican layouts on decreasing the healthcare safety net isn’t terrific politics or policy at the center of a pandemic and financial catastrophe. Which leaves a Enormous fat question … Read more

Not only can health plans pay for performance, they can offer a mechanism for confidential discussions of mistakes. Whoever said that talk is cheap never tried to run a modern hospital where the lesson that administrators seem to have taken most seriously is that too much talk — what with confidentiality rules and the threat … Read more

Project Orbis supplies an frame for concurrent entry and inspection of oncology medication one of its international partners. Under this job, the FDA, the Australian Therapeutic Goods Administration and Health Canada collaboratively reviewed software for just two oncology medications, permitting simultaneous conclusions in all 3 nations. “We’re happy to be working together with our Canadian … Read more

For 28 Years … The Leading Voice in Managed Care In-depth reports, original research, news, Q&As; with nationally respected health care leaders, and expert commentary on the latest developments in medicine, pharmacy, and biotechnology in relation to managed care. Managed Care delivers high-interest full-length articles and shorter features on clinical and business aspects of the industry. … Read more

These niche operators might help to keep hospital costs down and prevent some hospital-acquired conditions Asked if there is, in fact, such a thing as a proceduralist, Bradley T. Rosen, MD, the assistant director of the procedure center at Cedars-Sinai Medical Center, responds that the query is “very existential,” since he is one himself. Still, … Read more

A Couple of Years Back, like a relative Had Been Appreciating with a Bicycle ride From the countryside of western Pennsylvania, a truck pulled in front of him by the street road, leading to a dreadful mishap. As his mommy saw, the very first responders strolled his multiple cracks to prepare for a trip to … Read more

Health plans, researchers, employers, and workers make common cause to identify and treat depression Lola Butcher When Sprint Nextel, Hallmark Cards, and other Kansas City area employers decided to work together on a single health problem, step one was to survey workers about health risks. Step two was to pick a logical target. They chose … Read more

Heather Bresch had a rough day yesterday. The CEO of Mylan NV, the maker of the much-in-the-news EpiPen allergy shot, was grilled by the House Oversight and Government Reform Committee, Bloomberg reports. Committee members played hardball, questioning Bresch’s ethics and wondering just why she’s worth $19 million a year. At the center of it all: … Read more

Aetna U.S. Healthcare has offered a bare-bones product it says is a step toward reducing the number of uninsured Americans. But a consumer group says Aetna’s Affordable HealthChoices plans would leave patients with huge bills if they needed serious care. The three products pay $50 for a physician visit and $500 or more a day … Read more

By Gary Grubb, M.B.A. Whether you’re ready or not, capitation is coming to your neighborhood–if it hasn’t already moved in. Under capitation, of course, an HMO or other managed care organization pays you a fixed amount of money for each member enrolled in the health insurance plan each month. You are then responsible for any … Read more

Are You Prepared For the Next Recession? We’d hate to spoil anyone’s fun but the good times won’t roll on forever. You can, however, survive the next recession. COVER STORY Truce! Managed care and physicians are learning to get along. Is it a match made of necessity, or are the seeds of trust in place? … Read more

Health plan offers different cost guarantees in its No Worry and SmartResults consumer-directed programs Frank Diamond Humana is a forward-reaching company in the way a tree stretches toward the sun with roots firmly planted. The company has been getting some attention for programs that allow employers to sign up for multi-year contracts. Those programs — … Read more

A Brand New study Increases Troubling concerns that healthcare physicians don’t follow conventional precautions designed to protect them out of blood-borne pathogens. Conventional precautions Are the minimal disease control clinics that physicians must follow when looking after patients, whether they seem to be contagious. The study, published in the January topic of this American Journal … Read more

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

“For bicycles, such as the majority of companies, labour represents the most significant cost of providing services,” Feldbush explained. “economic activity because of their individual nation markets” and donated significantly more than 1.25 million occupations, America’s crucial ministry stated . A highly researched report from the Milken Institute School of Public Health at the George … Read more

What distinguishes the better-performing medical group practice from all the others? The Medical Group Management Association wanted to know, and now it does — at least, it has the numbers. You can’t quantify inspiration, dedication, skill, and attitude, but you can look at many of the outward characteristics of physicians and practices. MGMA put this … Read more

Cooperation between three health plans has fostered better employer appreciation of early detection and intervention in kidney disease. An employer-driven health coalition in western New York that has tackled hospital report cards, patient surveys, and asthma education among other projects has moved on to its next target — better identification, prevention, treatment, and education of … Read more

Pay-for-performance (P4P) programs may be especially effective in improving quality for those physicians who currently don’t perform well, according to a study in the Journal for Healthcare Quality. Judy Ying Chen, MD, lead author and director of clinical development at Health Benchmarks, a division of IMS Health, also says the positive benefit of the P4P … Read more

Latest Issue Table of Contents, June 2012 Download from App Store Read Digital Edition Download in PDF Resources Terms & Conditions for Using This Site Contact Us Disease Management Forum Call for Manuscripts Subscribe Address or Subscription Changes Rate Card BPA Statement Production Specifications for Ads and Inserts Classifieds Site Map Popular Content Disruptive Innovations … Read more

Even though physicians are highly trained and generally very intelligent (actually, at the top of all occupations in IQ, according to one study), they face a challenge with which we are all too familiar. There’s almost too much information out there, and not all of it good and sufficient for their needs. Is the therapy … Read more

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

Some Still Want To Know When There’s Nothing to Be Done Genetic Testing: Major Opportunity, Major Problems Whether a person is likely to develop diabetes, cancer, schizophrenia, or stroke will be reasonably well predicted, and tests can also determine whether a patient will respond to a given therapy. That’s the good part. Rocky Mountain’s Success … Read more

John La Puma, M.D. Five years ago, Managed Care published my first ethics column, and became the first medical publication to recognize that medical ethics was a needed, missing part of managed medical care. Dozens of conferences, hundreds of articles, and millions of hallway discussions later, managed care ethics is part of daily medical life. … Read more

Team Care and EHRs Are Key to Preventive Medicine Dean Field, MD The question facing health care organizations today is daunting: “How are we going to efficiently and effectively care for millions of new patients, many with chronic illnesses, and many who have never had access to routine health care in the past?” At Franciscan … Read more

Master the ‘ABCs’ of Activity-Based Costing Pam Schuneman, C.P.A., M.B.A. How do you find out whether a given capitation rate will be profitable for your practice? Activity-based cost accounting is one tool that can help. An accountant explains how it works. The last 10 years have brought substantial changes to the health care industry. Managed … Read more

A new practice-level financial model described in the report “Future of Family Medicine” estimates that a five-physician practice could see a 26 percent increase in compensation if it implemented this model and continued to use the current fee-for-service system of payment. That would be a change from $167,457 to $210,288 in mean total annual compensation … Read more

John La Puma, M.D. Capitation asks doctors to shoulder financial risk for their patients’ care. Capitation is defined as a flat “fee per head per time”: usually dollars per member per month. Capitation dollars are revenue, which is different from income. Income is what the doctor keeps after health care services are paid for. Bonuses … Read more

These medications have revolutionized the treatment of conditions like rheumatoid arthritis. But they are budget busters and have a tricky side effect profile. When rock musician Glenn Frey of the Eagles died at age 67 in January, the band’s website said the cause was complications of rheumatoid arthritis (RA), acute ulcerative colitis and pneumonia. But … Read more

The official name is the American Health Care Act and so the companion initialism is AHCA. Twitter was joking last night about how much trouble the addition of that measly H is causing. Other AHCAs like— this one(link is external) and this one(link is external)—are going to see more action on their Twitter feeds and clicks on their websites. Nicknames include GOPCare and Trumpcare, … Read more

Minnesota-based HealthPartners works with local leaders in a successful initiative to improve health care in a developing African country. REACHING OUT It’s a lush, agriculture-rich land in the Great Lakes region of East Africa. Once a British colony, it is now a country of 23 million welcoming, beautiful people who are inspiring and optimistic in … Read more

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

For patients with stage 1 Diabetes, low-dose chlorthalidone is Associated with decrease in bronchial blood pressure, whereas low-dose hydrochlorothiazide can cause masked hypertension, based on research published in the Feb. 2 issue of this Journal of the American College of Cardiology. Anil K. Pareek, M.D., by Ipca Laboratories Limited at Mumbai, India, and coworkers compared … Read more

The evolution of managed care has posed ethical problems for physicians, plan administrators, and even patients. Four ethicists find that questions are many, while satisfactory answers are in short supply. Daniel P. Sulmasy, MD, PhD PROFESSIONAL CONDUCT This summer, the American College of Physicians/American Society of Internal Medicine (ACP-ASIM) is scheduled to release a code … Read more

This is barely a blip on the screen and yet, just the fact that it’s being discussed in some places points to dissatisfaction with HMOs’ programs. Frank Diamond Senior Editor Even the slightest tremor in disease management can now move millions of health care dollars. And here’s one just tickling the seismograph: faint indications that … Read more

Determining return on investment and improvement of outcomes is essential when new programs are being tried, but the research method must be chosen carefully Introduction As wellness, case, and disease management programs proliferate, health plans must measure their outcomes and potential for return on investment. Here are a few strategies to help with that evaluation. … Read more

Since the discovery and following widespread use of antimicrobials, an assortment of pathogenic viruses, bacteria, protozoa, and helminths have generated a lot of mechanisms which render them immune for a –as well as in some specific situations, to most –anti inflammatory agents. The effect of the session of this workshop has been on researching several … Read more

Black-white differences in U.S. mature mortality have skyrocketed over the previous five decades, however if this narrowing unfolded to a time or cohort basis remains uncertain. The distinction has important implications for understanding the socio economic, public health and fitness, life style, and healthcare mechanics responsible with this particular specific narrowing. We utilize statistics from … Read more

  Less Carrot, More Stick? How Some HMOs Go Too Far Show Me The Outcomes! Some Medical Groups Prefer To Grow Their Own DM Programs Attention to Detail Crucial in Designing A DM Program Charts: Snapshot of a growth industry

Even if the the goal is unattainable in this country, working toward it might produce interesting experiments in cost efficiency Frank Diamond Managing Editor What might be overlooked in recent reports about the viability of pay-for-performance pharmacy programs is this: It can’t happen. Or, at least, it can’t happen here in the United States at … Read more

As we enter a year with a congressional election, candidates are unlikely to stir things up with imaginative, comprehensive proposals John Carroll Late last year, Emily’s List, a group of “pro-choice” Democrats, unveiled the results of a survey it feels clearly lays out a simple strategy on how that party’s candidates around the country can … Read more

The master program includes given that once an enrollee telephone reaches an idea customer support representative, the telephone is going to likely probably be categorized as a”grievance” automagically, as opposed to an”query” Misclassifying a grievance being a question denies enrollees in these legal right to take part from the program and also the DMHC’s grievance … Read more

Last May, two health advocacy groups filed a complaint with the Office for Civil Rights at HHS accusing four insurers selling plans in Florida of discriminating against people with HIV/AIDS by putting the drugs for treating the condition on the top tier of their formularies. Researchers at the Harvard School of Public Health have followed … Read more

By MargaretAnn Cross The timing couldn’t have been better when David R. Groves, PhD, vice president for corporate health management at Comerica, the large banking concern, received the findings of a study on the company’s employee health coaching program early last month. He had been preparing a talk for a disease management conference on outcomes, … Read more

Physicians will be harder to come by in 2020 if the data presented in Physician Workforce Policy Guidelines for the United States, 2000-2020 holds true. According to the report, the supply of practicing physicians in the United States is expect to rise 24 percent from 2000 to 2020. However, growth is expected to slow considerably … Read more

Health insurers can be doing more to come up with creative ways to pay providers and organize care There were skeptics from the beginning, a handful of experts who stood back and watched warily as others celebrated the push for accountable care organizations. ACOs, a much-touted part of the Affordable Care Act, were the way … Read more

Both health authorities that regulate the delivery and planning of the complete continuum of healthcare from British Columbia have expressed obligations to patient based care. Patient centered care is a method that expertly and meaningfully includes patients in their health decisions and travel. Patients that are active participants in their own care are proven to … Read more

In primary care, a productive interview is extremely important but hard to achieve as visits become shorter. The Bayer Institute offers some advice. By John Butler, M.D., and Vaughn Keller, Ed.D. As managed care increasingly imposes changes on health care delivery, many are concerned about how this will affect communication between clinicians and patients. Today, … Read more

Anthem’s experience exposes vulnerabilities regarding the maintenance of physician networks Health plans need ironclad cases against doctors they exclude from their networks or it could cost them. A jury in Los Angeles last month awarded $3.8 million in compensatory damages to Jeffrey Nordella, MD, a primary care physician whose application to join the Anthem Blue … Read more

More than a third of Americans who need to be screened for colon or breast cancer have not been screened, according to the latest report from the Centers for Disease Control and Prevention. But overall, more people are being screened than ever before. “We are encouraged by a significant increase in colon cancer screening rates … Read more

MedPartners Inc., which made a fast fortune as the world’s biggest physician practice management company, then lost it almost as quickly, changed its name to reflect the shift of its business to pharmacy benefit management. The company already owned Caremark, the PBM, so renaming itself Caremark Rx Inc. was a natural…. Tufts Health Plan will … Read more

By Jean Lawrence Contributing Editor Nobody is calling asthma an epidemic, but the disease is reaching epidemic proportions. Diagnosis is up 40 percent from the mid-1980s. More than 12 million Americans suffer from it, and treatment accounts for 1 percent ($6.1 billion) of America’s sky-high health care costs. Add to the tab another $1,033 per … Read more

Racial disparities in cancer deaths between white and black patients from the USA are receding — yet further progress is necessary to completely close the difference forsome cancer types and age classes, according to another study. Among women, the disparity dropped from 19 percent in 1990 to 13 percent in 2016 and has been not … Read more

At the USA, over 25 million people suffer diabetes. Medication adherence is well considered to be crucial for disease control. But factors that always predict drugs adherence are uncertain and also the literature eliminates patient viewpoints about what medical care systems change adherence to oral hypoglycemic agents (OHAs). A total of 45 patients engaged in … 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

The Food and Drug Administration Declared the Nextgeneration sequencing (NGS)-established FoundationOne CDx evaluation like a companion diagnostic to spot fusions from neurotrophic receptor tyrosine kinase genes, including NTRK1, NTRK2, and NTRK3, at DNA isolated from tumor tissue samples from patients with solid tumors qualified to receive treatment using larotrectinib. For pediatric and adult patients with … Read more

Biotech Med Ixekizumab (Taltz) Wins FDA Nod for Treatment of Plaque Psoriasis Treatment will be available in second quarter of 2016   The FDA has approved ixekizumab (Taltz, Eli Lilly) injection 80 mg/mL for the treatment of moderate-to-severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. Ixekizumab is designed to … Read more

State budgets got an unexpected gift last year. Medicaid spending declined in 2006, the first time that has ever happened. Medicaid spending fell 1.4 percent in the first nine months of 2006, USA Today reports. After adjusting for the rate of health care inflation, the decline was 5.4 percent…. Regence BlueShield has decided not to … Read more

By Mark D. Abruzzo, J.D. Caught in the riptide of change, hospitals in many regions have ventured into the private practice of medicine in the past 10 years in an effort to maintain an adequate stream of referrals. Many have formed “networks” by purchasing primary care practices. At present, all is fairly quiet on the … Read more

The new rush of advertising and practice advancement will incorporate web-based media organizing. This article will talk about Facebook and Twitter. In the wake of perusing this article you, will have a comprehension of these two significant parts of online media and how you may utilize Facebook and Twitter in your training to upgrade your … Read more

Website doctors miss major diagnoses   Researchers posing as patients with skin problems sought help from direct-to-consumer (DTC) telemedicine websites––with troubling results, according to a study published in JAMA Dermatology. Some of the online doctors misdiagnosed syphilis, herpes, and skin cancer, and some prescribed medications without asking key questions about patients’ medical histories or warning … Read more

With a kind of lung cancer, completely removing any hint of disorder from 1 patient. Directed by investigators at the University of Surrey, U.K., included fifteen patients that were treated using a virus identified as CVA21, a naturally occurring virus that causes the frequent cold, with a few striking outcomes. The Kind of cancer from … Read more

  NCQA’s New Rating Scheme To Allow Easier Comparison NCQA hopes its revamped accreditation process and documents modeled on Consumer Reports will mean more use by employers and the public. Michael D. Dalzell You Can Drag Physicians To Guidelines… But You Can’t Make Them Comply (Mostly) Studies show that doctors often ignore the recognized expert-tested … Read more

A huge database of diabetes patients unveiled last month will be used to try to improve care for patients. The database, called the SUPREME-DM DataLink (derived from SUrveillance, PREvention, and ManagEment of Diabetes Mellitus) includes health information for nearly 1.1 million diabetics in 10 states. The information was contributed by Kaiser Permanente (six regions), Geisinger … Read more

The National Committee for Quality Assurance and the AMA hit upon an agreement intended to reduce paperwork for physicians. NCQA will allow health plans to use data from AMA’s American Medical Accreditation Program to satisfy NCQA’s credentialing standards. Though only a smattering of health plans use AMAP physician-credentialing standards, the AMA expects many more to … Read more

The new director of HCFA’s Center for Health Plans and Providers wants to bring managed care options to Medicare recipients and overhaul guidelines governing payment rates for cognitive services. Two decades after serving on the White House domestic policy staff for President Carter, Robert A. Berenson, M.D., once again is working full time in the … Read more

Value of successful leadership in trading businesses has grown. The issue that trading businesses face is it is tricky to obtain a dealer that is likely to earn a excellent pioneer, yet it’s all but hopeless to be a highly effective leader of a commodity trading operation without even trading encounter. The Objective of the … Read more

A few major corporations, sometimes with the assistance of a traditional health plan, have made significant efforts to improve employee lifestyles Every week, members of a missionary group of registered nurses and health educators fan out to 165 Hannaford Supermarkets, scattered across the country. And for a short, focused break, on company time, moving mountains … Read more

State legislatures that tackle medical group insolvencies have come up with strategies that sometimes shift accountability to HMOs. In November 1999, Maryland surgeon Holuk Boneval suddenly found himself with 15 percent fewer patients, but not by choice. Boneval and some 400 colleagues belonged to Dimensions Health Network, a Maryland physician-hospital organization. Over the course of … Read more

  Will Integrity of HEDIS Data Improve with ’98 Version? At first glance, the ’98 HEDIS looks a lot like the ’97 model. But lift the hood and you’ll find that NCQA re-engineered HEDIS to give better performance, thanks to improved data-collection techniques. Michael D. Dalzell JCAHO’s Oryx Initiative Links Outcomes with Accreditation By March … Read more

Boiling down the complex and often dense (at least to laymen) medical information that’s distributed with prescriptions into one page of easily understood data seems to encourage patient engagement, according to a study by Catalina Health, a health care communications company. The study is the result of an improvement effort by Catalina and the Engelberg … Read more

Employers Interested In Disease Management — If It Brings a Return Tomorrow’s Technology Is Saving Money Today The camera never lies, goes the adage. A growing number of physicians and health care providers are using that bit of wisdom to cut costs while making patients’ lives better. Too Many Books: How To Tell the Best … Read more

POPULAR CONTENT TODAY’S POPULAR CONTENT Type Title Author Story Do You Always Make Sure Patients Get Test Results? webadmin Story UnitedHealthcare’s Bold Effort to Deal with Cancer Drug Costs webadmin Blog entry Discrimination and Health Status Steven Peskin MD Story Cardio and CNS drugs deliver bulk of generic savings webadmin Story Stroke Rehabilitation Requires Knowing … Read more

The diagnostic procedure has medical promise, but a lack of utilization guidelines raises questions about resource use and keeps payers away. Paul Carson MANAGED CARE September 2001. ©MediMedia USA DEMAND MANAGEMENT The diagnostic procedure has medical promise, but a lack of utilization guidelines raises questions about resource use and keeps payers away. Paul Carson HealthScreen America has … Read more

First Patient Expected to Receive AMT-130 Therapy in 2019 uniQure N.V. has received a fast track designation from the FDA for AMT-130, a gene therapy candidate for the treatment of Huntington’s disease. The agent comprises a recombinant AAV5 vector with a DNA cassette encoding a microRNA that non-selectively reduces human huntingtin protein in patients with … Read more

Managed care take a bite out of fraud? Hardly. It has merely changed some of the techniques of stealing and corner-cutting. Jean Lawrence Contributing Editor MANAGED CARE October 1997. ©1997 Stezzi Communications Undertreatment Endangers Patients Managed care take a bite out of fraud? Hardly. It has merely changed some of the techniques of stealing and corner-cutting. Jean … Read more

Drug repurposing goes by a lot of names—some less flattering than others—but put simply, repurposing involves applying a drug’s mechanism of action to an indication far from its original intended use. The best-known example may be sildenafil (Viagra), which failed in early trials as a hypertension agent but became a household word after men in those studies … Read more

CMS and states may stop paying for specific hospital-acquired conditions. Will health plans follow suit? Hospitals are under increasing financial and legal pressure to eliminate egregious medical errors. States, consumer organizations, and now the federal government are pushing hard to create accountability. They believe that withholding payment to hospitals for the extra care that results … Read more

A new practice-level financial model described in the report “Future of Family Medicine” estimates that a five-physician practice could see a 26 percent increase in compensation if it implemented this model and continued to use the current fee-for-service system of payment. That would be a change from $167,457 to $210,288 in mean total annual compensation … Read more

A majority of patients in consumer-directed health plans do not understand their coverage options and about 20 percent will skip preventive care because of cost, even though the services are free or very inexpensive. Those are some of the findings in a study by Kaiser Permanente Northern California, which found that “consumers rarely understood that … Read more

Aetna U.S. Healthcare will launch a series of products Jan. 1 that will drop the gatekeeper function. In most cases, the new plans, called Aetna Open Access, will allow members to receive care from specialists without a referral from their primary care physicians. Meanwhile, HealthPartners, the Minneapolis-based health system and HMO, plans to offer its … Read more

Rush to Robotic Surgery Outpaces Medical Evidence, Critics Say Hospitals are hyping better outcomes with the robot, but economics and marketing may be driving the push Richard Mark Kirkner The Promise and the Pitfalls of Reference Pricing Payers attracted by the siren song of this cost-cutting strategy don’t always appreciate its risks and complications Peter … Read more

EMPLOYER UPDATE Employers are beginning to tap into the groundswell of employee interest in reducing premiums. MargaretAnn Cross HCA’s employee newsletter has been focusing a lot on health care issues over the last two years, says Bob Read, director of benefit planning and design. HCA, which owns about 180 hospitals and employs 185,000 people in … Read more

The former head of CMS takes Congress to task. The ACA is not perfect (no law is) but could be improved, in his view, if only lawmakers would show more political courage. In January 2017, as the Trump administration took office, Andy Slavitt cleaned out his desk as the acting director of CMS and headed … Read more

Type Title Author Story We’re All on Best Behavior When Others Are Watching webadmin Story HHS Report: HCFA Is Not Keeping Up On Managed Care webadmin Story Headlines On Deadline … webadmin Story Physician Satisfaction Study Surprises webadmin Story Citing Losses, Florida Closes Troubled Plan webadmin Story DTC Ads Hit Mark, Drive Increases In Office … Read more

When it comes to balancing the role of business owner and practicing physician, many private practice doctors are having a tough time of it. One quarter of the physicians surveyed by American Express describe maintaining the dual role as “extremely challenging,” while 58 percent describe it as “challenging.” Nearly half (43 percent) of all physicians … Read more

While managed care has helped reduce the average length of stay in hospitals, it doesn’t seem to have affected hospital profit margins — at least until very recently. In fact, those margins rose between 1993 and 1997 as the average length of hospital stay dropped. Meanwhile, HMO profit margins dropped. Color charts

Twitter and Facebook are good places to promote a health plan’s brand, and they can help members by reinforcing positive behaviors John Carroll Contributing Editor Back in early 2008, the not-for-profit Minnesota-based insurer HealthPartners decided to create a presence for itself in the newly emerging world of social media. Rather than promote the insurance side … Read more

This versatile physician holds the view that the Institute of Medicine actually understated the number of medical errors. He also doubts that the usual prescriptions for reducing errors will be effective. David Classen is a clinical infectious disease physician, a medical epidemiologist, and a medical informaticist. His work in improving patient safety has included use … Read more

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

This time the messenger matters as much as the message. Are specialists gearing up for life after fee-for-service? When Donald M. Berwick, MD, CEO of the Institute for Healthcare Improvement (and recently the director of the Centers for Medicare & Medicaid Services), calls something a game-changer, notice must be paid. Newspapers across the country report … Read more

Three health plans outline steps they are taking to deal with the effects of growing consolidation of providers Joseph Burns For Georganne Chapin, a report that hospitals and physicians were wielding increased market power in several cities was not news. The president and CEO of the not-for-profit Hudson Health Plan in Tarrytown, N.Y., was well … Read more

International trial follows more than 9,000 patients for up to five years Novo Nordisk has announced results from the LEADER trial, which investigated the cardiovascular safety of liraglutide (Victoza) during a period of up to five years in more than 9,000 adults with type-2 diabetes at high risk for major adverse cardiovascular events. The LEADER … Read more

Is diagnostic support software good news for both physicians and HMOs? Yes, say the companies selling such programs, who contend that they can “put the fun back in practicing medicine.” Your practice administration is computerized; you communicate with colleagues via E-mail; maybe you surf the Internet after dinner. But if you’re like most physicians, you … Read more

It’s been suggested that, in order to battle obesity, HMOs should use their collective information and knowledge to change their members’ behavior. Are they ethically or morally responsible for doing anything? That’s one question. Here’s another: Assuming, for the moment, that they are ethically and morally responsible for acting, should they be held legally accountable … Read more

Only a small percent of a typical health plan’s population takes medicine for conditions outside the generalist’s scope. But it’s a big portion of the drug bill. Alan Lotvin In recent years, there’s been a flood of new high-tech specialty drugs used to treat an increasing number of complex and chronic conditions such as anemia, … Read more

Last year, the Bureau of Labor Statistics, the statistical arm of the Department of Labor, estimated that pharmacist employment was expected to grow by 22 percent between 2006 and 2016. This year, the forecast is somewhat lower, but still hopeful. The BLS reports that pharmacist employment is expected to grow by 17 percent between 2008 … Read more

The cost-sharing techniques that employers use in prescription drug benefit designs vary, but across types of health plans, there is remarkable similarity. For instance: Separate copayment levels for brand-name and generic drugs is the most common technique that employers use, but it’s not necessarily seen more often in an HMO than in, say, a PPO. … Read more

Cardiovascular disease (CVD) is primarily a disease of old age. But it’s certainly capable of cutting down people in the prime of life, something that worries the World Health Organization (WHO) and U.S. health officials. The WHO wants to see a 25% reduction in premature mortality (death between ages 30 and 70) caused by CVD … Read more

If managed care is giving you figurative ulcers, at least it offers the promise of helping you treat real ones, too. Many physicians are now aware of the recent discovery that it’s not job stress, tequila or chicken cacciatore that’s at the root of most peptic ulcer disease, but a spiral-shaped bacterium called Helicobacter pylori. … Read more

Before enrolling in a consumer-directed health plan (CDHP), people may want to take stock of their financial assets. Relatively few uninsured households have enough financial assets to cover the cost sharing in CDHPs that are tied to a health savings account (HSA), according to a recent study conducted by Kaiser Family Foundation researchers and published … Read more

3: Nevada, New Mexico, and Oregon have authorized state-run exchanges but are using the federal exchange for many enrollment functions. If King prevails, it’s not clear how the court decision will affect these three states. 3: As Lyle Denniston and others have written, the premium subsidies at issue in King v. Burwell are one of the legs of the … Read more

I was amused and somewhat unsettled when I heard of Kaggle, a company with a novel approach to data analysis. As I understand it, Kaggle is a middleman between companies that have large amounts of data and are looking for certain kinds of analysis and the people or companies that can provide that analysis. But … Read more