As a seasoned political observer of Oregon politics, Christy Quirk thought Measure 23 had just about everything going against it. It called for a single-payer insurance system that brazenly highlighted the higher income and payroll taxes that would be used to pay for it. The organizers had few allies who could muscle support. They had … Read more

DOT COM Some pretty amazing stuff was on display in Dallas. Where were those most-sought-after potential buyers — physicians? John Carroll Barry Martin spent much of 1999 buried in his basement office in Halifax, Canada, feverishly working on the prototype for his home-monitoring telemedicine device. With a tiny camera and a speaker, Martin’s new gadget … Read more

Call it the nature of the fragmented U.S. health care system — U.S. physicians spend nearly four times as much money interacting with insurers and health plans than their counterparts north of the border, according to a survey from the Commonwealth Fund published in Health Affairs. Those administrative costs amount to $82,975 per physician per … Read more

If you’re like most physicians, the only price tag you worried about in medical school was the one on your education itself. It’s a different world today, as this pediatric cardiologist, teacher and administrator explains. A dozen second-year medical students were gathered around a hospital seminar table, and I was their preceptor. They had been … Read more

One auditor estimates that 3 percent to 10 percent of PBM claims are processed incorrectly — always in favor of the PBM. As the rising cost of health care continues to be a national concern, all facets of pharmaceuticals, from manufacturing to distribution, are caught squarely in the health care klieg light. Pharmacy benefit managers, … Read more

The U.S. Preventive Services Task Force now published a draft recommendation announcement on screening for esophageal cancer. For first time, the Task Force is recommending that viewing beginning at age 4-5. This is ab recommendation. The taskforce has been highly recommend screening men and women that are 50 to 75 yrs of age. This really … Read more

Cover Story Get Full Picture of Imaging Overuse Some health plans do a good job clamping down on PET, CT, and MRI technologies, whose costs can grow even faster than pharmacy. Despite this success, serious doubts remain about whether imaging use can be contained in the long run. Promoting Breast Cancer Screening Insurers have come … Read more

Does Supreme Court’s Tilt Portend Problems for HMOs? The states-friendly Rehnquist Court may eventually have to decide on anti-managed care laws flowing from state capitals. COVER STORY Bigger Isn’t Always Better So you think consolidating with another health care business will help? It might, but success depends on more than size. California Physicians Struggling – … Read more

Scientists at the University of Zurich in Switzerland have been able to understand for the first time why many cancer cells quickly adapt to treatment with therapeutic antibodies in invasive forms of breast cancer. Instead of dying off, they are merely rendered inactive. The researchers have developed an active protein compound that kills cancer cells … Read more

Recent reports question whether statins are being overprescribed Martin Sipkoff Statins are the best-selling drugs in the world, with more than 25 million people, including 13 million Americans, spending $27.8 billion on the cholesterol drugs in 2006, according to IMS Health. About half of that was for Pfizer’s Lipitor, which last year had $18.4 billion … Read more

Doctors have been installing electronic health record systems at a brisk clip in the last few years, but those systems might not be able to do everything that’s needed for the owners to qualify for meaningful use incentive payments, according to the Centers for Disease Control and Prevention (http://tinyurl.com/EHR-data). “From 2011 to 2012, the percentage … Read more

Interest in consumer-directed health plans lost steam last year, with the number of employers offering such plans declining for the first time since 2007, according to United Benefits Advisors, a benefit survey organization. The 2012 UBA Health Plan Survey calls this a critical trend that its employer customers should consider “when making health plan purchasing … Read more

Plans and payers are looking at a new insurance design that puts quality first. It might also save money. Health care costs are astronomical and premiums are rising. As a result, a basic question about private health plans is being asked by the public, payers, the federal government, and the media: What value do health … Read more

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 result of many … Read more

A unique health plan-provider partnership focuses on giving practical knowledge to those to whom the CEOs report The Wall Street Journal and the business pages of other major newspapers will often run stories about the board of directors of a company making a decision that affects billions in revenue and thousands of lives. But just … Read more

Healthcare reform has attracted many players into the dining table. Along with also the”match” is certain to get losers and winners. This match is comparable to this game Monopoly — a range of healthcare businesses are buying up land (i.e., hospital and also more compact providers) to put themselves as winners at the brand new … Read more

This subcutaneous non-factor representative was extensively qualified for the prophylaxis of patients of all HA patients without FVIII-inhibitors of most ages, but some data are available in kiddies. In Phase 3 clinical trials as well as set, emicizumab prophylaxis considerably reduced bleeding levels in contrast to previous treatment in HA teens and kids without FVIII-inhibitors … Read more

The gender imbalance in health care leadership is a problem worth solving, experts say. That will require women willing to step forward—and men willing to back them. It has been said often and for a long time that women are the health care CEOs, CFOs, COOs, and CMOs of their families. But when it comes to … Read more

A The 30day readmission pace in the USA is currently 18 percent depending on recent research workers, and also the price of readmissions among Medicare beneficiaries can be definitely an estimated $17 billion yearly. It’s Been ascertained that a few hospital readmissions are preventable, And also a centre’s rate of readmission is presently used as … Read more

Therapeutic interchange is the custom of changing or administering drugs which are chemically different however therapeutically similar concerning their efficiency, safety, and tolerability profiles. The stated goal of healing interchange is always to attain a better or impartial outcome with the brand new broker when reducing overall treatment expenses. Until recently, many inter change programs … Read more

Health Plans Cautiously Optimistic as ACOs Enter Prime Time Leaders of managed care and of many provider organizations find that they can work together better than ever before Whatever you might think about accountable care organizations — fix, folly, something confusing in between — one thing is clear: What was once an ivory-tower idea is … Read more

Is it a simple matter of pay for volume vs. pay for value, or is the situation far more complicated? CareFirst, the Maryland–Washington Blue Cross Blue Shield plan, has transformed its first-generation oncology pathway program into a second-generation program that incorporates medical home principles. The change reflects CareFirst’s continuing effort to encourage oncologists to improve … Read more

Mary Dorholt, PharmD Plan sponsors are wasting $4.9 billion annually as a result of inadequate management of specialty medications in the medical benefit, according to our estimates using MarketScan data. Most of these costs could be avoided by applying the utilization- and trend-management programs that are traditionally found in the pharmacy benefit to the medical … Read more

Lower Copays Sweeten Outcomes-based Deal for Brilinta The contract between UPMC Health Plan and AstraZeneca will help the brand-name antiplatelet drug compete against generic versions of Plavix by lowering the copay to $10. Modest, at best: The effect of getting rid of copays for antiplatelet drugs A study designed to test whether eliminating copays would … Read more

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

Once in a while something comes up that requires the sort of immediate and intense intervention that’s downright heroic Let’s start with the happy ending. On March 30, the Food and Drug Administration, in a highly unusual move, ruled that compounding pharmacies could still sell 17 hydroxyprogesterone caproate (17OHP), used to prevent babies from being … Read more

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

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

The first report issued by the Health Care Cost Institute made headlines last month not only for what it says but for how it came to say it. “Health Care Cost and Utilization Report: 2010” crunches 3 billion claims for more than 33 million members of three of the biggest health plans: Aetna, Humana, and … Read more

The noted and newsworthy attorney general of New York is taking aim at some of the biggest middlemen in the insurance business. Tim Elenz has few illusions about the competitive world of health insurance brokers. The head of Elenz & Associates is a self-described street-taught kid who grew up in Chicago, and through the years … Read more

Flashback: Ten Years Ago, Measuring Patient Satisfaction Was the Next Big Thing Consumer-Directed Health Care: Too Good To Be True? People talk about it as the sure way to control costs and give consumers the choice they seem to want. Are we being realistic? Pharmacy Benefit Starts To Reflect Push for Consumer-Directed Care Plans looking … Read more

The industry has been criticized for lack of transparency—and worse. Some see ‘a ton of sense’ in the proposed mergers with insurers and retailers. Others see a risk of even higher drug prices and a need for oversight. Three years ago people in health care circles were congratulating Express Scripts for negotiating a significant discount … Read more

There’s really a sea change occurring in Western hospitals and healthcare businesses. We’re seeing a radically changing healthcare environment by which physicians and hospitals are looking forward for a decreasing little bit of their settlement pie, even as the feeforservice version of compensation gives solution into the value-based version. Physicians and payers, in Addition to … Read more

There’s a lack of definitive information about the possible benefit or harm of screening for oral cancer, the U.S. Preventive Services Task Force finds, so the panel refuses to recommend for or against such screening. Cigarette smoking, alcohol consumption, and HPV are the most common causes of oral cancer. The panel reviewed several studies that … Read more

People who buy nongroup or individual insurance say their premiums have increased an average of 20 percent, according to a survey by the Kaiser Family Foundation. This increase has spurred 16 percent of them to search high and low for a better price for the coverage they want, but they’re coming up short. Buyers who … Read more

The former Vermont governor at first greeted managed care with good will. Now, however, he thinks it is shortsighted in its dealing with doctors. Unlike President Bush, he wouldn’t call on it to rescue Medicare. The former Vermont governor at first greeted managed care with good will. Now, however, he thinks it is shortsighted in … Read more

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

Reducing paperwork, coordinating guidelines, and credentialing physicians are three areas being explored without damping the competitive spirit. Too much paperwork is a perennial physician complaint, the American Medical Association says. Doctors hate filling out forms. In Philadelphia, even a $225 incentive couldn’t entice more than 50 percent of physicians who saw pregnant women enrolled in … Read more

Physicians Say Quality of Care Declining Despite advances in medicine, a majority of physicians in the US and a large percentage of doctors in major industrialized countries say that the quality of care they are able to provide patients has deteriorated over the past 5 years, according to survey results released Thursday morning. [Reuters via … Read more

For all the money he spent on his MBA, Ted Okon says the best life lesson he ever received cost him $80. It came from a guy dealing Three Card Monte on a New York City street corner. He was up $40 but in no time lost that $40 plus $40 more. So what lesson … Read more

The FDA’s Peripheral and Central Nervous System Drugs Advisory Committee has announced that it will discuss the new drug application for eteplirsen (Sarepta Therapeutics) on April 25––nearly three months after the original action date. Sarepta is seeking approval for the treatment of Duchenne muscular dystrophy (DMD) in patients who have a confirmed mutation of the … Read more

Plans and health systems are collaborating with walk-in centers to keep patients out of the ERs. Investors like what they’re seeing. In some cities, the hospital CEO casts a wary eye when an urgent care center opens in the hospital’s backyard, but in northeastern Massachusetts, things have changed. There, Lahey Health, with five hospitals and … Read more

Coverage may now come with built-in access to a level of case management that some HMOs find useful. Health care business relationships in which all parties’ interests appear to be perfectly aligned? Well, perfectly may be pushing it, but reinsurers can make a pretty good case that holding down claim payments to a health plan … Read more

Michael Levin-Epstein Washington Watch 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 … Read more

When 32 million or more new members, courtesy of the Accountable Care Act, are just not enough China’s 1.4 billion people have state coverage for their health care, a legacy of the communist regime that took power 64 years ago. But it’s far from comprehensive these days. Outpatient costs are typically borne by individuals. About … Read more

The rush to create consumer-directed health plans might not go as far as some hope, based on findings in a recent study by the Institute of Medicine that says that about 90 million people have difficulty reading and understanding medical information. Consumer-directed plans typically have deductibles as high as several thousand dollars, health reimbursement accounts, … Read more

The recently approved human papillomavirus vaccine is a prime example of how science is beating back the advance of old diseases As you no doubt know, several weeks ago the FDA approved of the first vaccine developed to prevent cervical cancer, precancerous genital lesions, and genital warts. This vaccine prevents infections caused by the human … Read more

Physicians are quick to lament that the time-suck of EHRs, however, many also acknowledge that they’d not return straight back again to paper records. Last week, a Buffalo hospital has been made to put that notion into the evaluation. This week following a virus closed down IT systems early Sunday afternoon, according-to The Buffalo News. … Read more

THE DARK ARTS OF FORMULARIES AND REBATES COMING TO LIGHT Rebates have created pay-to-play dynamics. Employers facing high drug costs have “rebate addiction.” And the impressive “rebate guarantees” are hard to resist. But at least the process of how drugs get formulary placement is becoming clearer, and some PBMs have moved to charging administrative fees … Read more

By Marc Mandell, J.D. I’ll never forget the response a physician client of mine gave one day when I asked him if he had told a patient the results of a test that had been performed at a certain hospital. “That’s the hospital’s problem,” he said. He was wrong. Most courts have ruled that a … Read more

Abstract Tele-ICU could be the usage of an offsite control centre in that an essential care team (intensivists and critical care physicians ) is correlated with patients in remote ICUs to swap health advice through real time sound, visual, and digital ways. The goal of this analysis is to examine the literature linked to the … Read more

All the excitement in the industry about Medicare PPOs died in a hurry last month as the Medicare Payment Advisory Committee (MedPAC) moved closer to recommending that the $10 billion fund for the program be eliminated. MedPAC voted to adopt a draft recommendation that lawmakers eliminate the fund in order to help slow the growth … Read more

The recent U.S. Supreme Court decision offers a nice breather, but executives should not let down their guard, as an Illinois ruling shows.   The recent U.S. Supreme Court decision offers a nice breather, but executives should not let down their guard, as an Illinois ruling shows. HMOs should not delude themselves about the U.S. … Read more

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

States have been having a tough time in recent years trying to make the federal Medicaid funding stretch farther. Some have resorted to limiting enrollment. Others have turned to managed care to the point where 1 in 3 beneficiaries now receive care through a health plan. It seems to be working — perhaps too well. … Read more

An electronic device is applied to the forehead in a 40-minute treatment, causing depolarization of neurons Thomas Morrow, MD Depression has been described as a human condition in some of the oldest writings. In fact, the Old Testament gives indications that King David and Job may have had symptoms of depression. The cause of depression … Read more

Services and solutions to the pharmaceutical, biotechnology and medical device businesses, today announced it has been selected by the International Consortium for Health Outcomes Measurement to progress value-based health through the launching of some world wide healthcare effects benchmarking program named GLOBE. ICON is which consists of data management, data analytics and consultancy expertise to … Read more

A survey of 500 HSA enrollees finds that 82 percent are satisfied with their accounts and 91 percent believe such accounts should remain an option for Americans. More than 80 percent of respondents cite their ability to save for future health care expenses as the primary reason for opening and depositing money into their HSAs. … Read more

Origin of Mandates Wasn’t Spontaneous Generation Per-Patient Visits to Behavioral Therapists Drop 63% in Just Two Years, Study Shows The Waiting Game: Managed Care & Dentistry Combined managed health and dental coverage could save expenses for employers and improve care. But neither employers nor traditional managed care plans have shown much interest in packaged plans. … Read more

Whether you define managed care as a treatment philosophy or a payment mechanism, it’s here to stay. Regardless of the mutations managed care has undergone in the last decade-plus, it is an entrenched part of the health care system — as confirmed by a recent study of physician practice revenue by the Center for Studying … Read more

Two-thirds of American adults surveyed in a Wall Street Journal/Harris Interactive poll say that increasing out-of-pocket health care costs will deter people from seeking health care services when needed. Further, the majority say that the increase will harm the public’s health. One third say that the increased costs will encourage people to make better decisions about … Read more

Minnesota’s five largest health plans and three major provider systems, including the Mayo Clinic, have agreed to use a standard set of evidence-based treatment guidelines developed by the Institute for Clinical Systems Improvement, a Bloomington-based quality-improvement consortium. The ICSI, founded by Mayo and other large regional provider organizations, developed a system in which physicians evaluate … Read more

Letters to the Editor Is Care Coordination Making Carve-outs Less Desirable? Health plans are evaluating whether to stop carving out drug benefits, disease management, and even behavioral health management Martin Sipkoff Will Biomarkers Bring Smarter Care? Expanded blood testing can reveal much about individuals’ health risks, but how should health plans decide on coverage? Steven … Read more

Harvard researchers investigate ‘adverse tiering’ 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 … Read more

Patients can go up to two weeks between infusions The FDA has given the nod to Idelvion (coagulation factor IX [recombinant], albumin fusion protein, CSL Behring), a long-acting albumin fusion protein linking recombinant coagulation factor IX with recombinant albumin for the treatment of patients with hemophilia B. Idelvion is the first factor IX therapy that … Read more

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

New tests will allow better determination of which therapies will work on which patients, thus improving care and reducing outlays for failed therapies. Thomas Morrow, MD MANAGED CARE November 2004. ©MediMedia USA New tests will allow better determination of which therapies will work on which patients, thus improving care and reducing outlays for failed therapies. Thomas Morrow, … Read more

Human beings are not machines, and modern medicine needs to move beyond the repair shop mentality. Could nontraditional services help? Albert Einstein said that you cannot solve a problem with the kind of thinking that is creating the problem. Modeling our health care system after the machine repair shop has forced us to make difficult … Read more

The medical home model for delivering health care is getting tested for people with mental health problems. Missouri has been a pacesetter. Providers often get frustrated when called on to care for the mentally ill, says Joseph Parks, MD, of the National Council for Behavioral Health. “They’re more difficult to engage and to communicate with.” … Read more

Salaries of medical directors and associate/assistant medical directors have risen by more than 30 percent over the last 10 years, according to the 2007 Cejka Search/American College of Physician Executives Compensation Survey. In 1997, medical directors earned an average of $175,000; associate/assistant medical directors earned an average of $160,000. In 2007, salaries of medical directors … Read more

Washington Watch Do two recent advisory opinions from the Health and Human Services Office of the Inspector General signal some moderation in federal policy on what constitutes a kickback? Maybe. Or then again, maybe not. Consider the case of a not-for-profit hospital, which operates a cancer facility at its main campus plus a satellite center … Read more

No longer passive, companies are working in a variety of ways to improve employees’ care. Are health plans being left behind? Frank Diamond Managing Editor MANAGED CARE August 2007. ©MediMedia USA No longer passive, companies are working in a variety of ways to improve employees’ care. Are health plans being left behind? Frank Diamond Managing Editor Helen … Read more

Addressing the problem of the uninsured remains tricky owing to the fact that the number of those who find themselves in such circumstances for long periods of time varies considerably from the national average of 11 percent, according to the 1999 National Survey of America’s Families. In fact, length of time being uninsured seems to … Read more

BY JOHN LA PUMA, M.D. Alternative medicine is the politically acceptable term for nonallopathic health practices, usually unavailable in physicians’ offices or hospitals, that are very popular among our patients. Alternative medicine encompasses mind-body interaction, homeopathy, naturopathy, chiropractic, botanical medicine and more. Diagnostics range from detailed examination of the pulses and tongue in Oriental medicine … Read more

Pennsylvania has been one of the states hardest hit by the opioid epidemic, with more than 3,500 people dying from the drugs last year. Michael Ashburn, MD, MPH, guest blogs today on the Philadelphia Inquirer’s health section and points out that the epidemic started with the best of intentions: relieve pain. Ashburn blogs: “Over the years … Read more

Donna J. Senft MANAGED CARE February 2002. ©MediMedia USA Donna J. Senft A federal court in Maryland recently addressed challenges to several laws governing physician credentialing. The challenges arose when a physician whose hospital privileges were revoked filed a civil action against the hospital and 14 individuals involved in its credentialing process, along with the state of … Read more

Despite the higher costs of SSRIs, compared to older antidepressants, limiting members’ access can lead to undertreated depression In a practice that is perhaps best described as penny wise and pound foolish, many health plans and pharmacy benefit management companies fail to include several selective serotonin reuptake inhibitors (SSRIs), among the most effective treatments for … Read more

Cover Story MANAGED CARE April 2012. ©MediMedia USA To paraphrase Mark Twain, the death of the health insurance industry has been greatly exaggerated. Plans simply have to develop new business models. Joseph Burns Contributing Editor Experts predict the end is near for health insurers. In an article in the New York Times on January 30, Ezekiel J. Emanuel, MD, … Read more

Year:  2011  |  2010  |  2009  |  2008  |  2007  |  2006  |  2005  |  2004  |  2003  |  2002  | 2011 January Cover Story UnitedHealthcare’s Bold Effort to Deal with Cancer Drug Costs ACOs Will Depend on HIEs, With an Assist From Plans Vision Plans Hope to Gain Access To State Insurance Exchanges Can Self-Management Programs Ease Chronic Conditions? Managing Fibromyalgia: Supporting self-management brings … Read more

Retail stores offer “young invincibles” and the working poor the chance to examine low-cost coverage options Officials at Blue Cross & Blue Shield of Florida didn’t plan for this. They couldn’t have. They launched their Florida Blue stores in 2007, well before it was clear that President Obama would be the current occupant of the … Read more

Lose data stored on a hard drive and your practice will suffer for months. It’s a real threat, so head off catastrophe with backup disks, tapes and systems — before it’s too late! Anne Bilodeau Zieger Contributing Editor It can happen in seconds: a few wrong keystrokes and — zap! Days or even weeks of … Read more

Now that the value of hospitalists is well established, attention turns to those whose only duties are in intensive care Lola Butcher Joan Brookhyser, MD, is on a mission to change the face of health care in Nevada. Much to her surprise, her opportunity is coming from the largest HMO in the state. In the … Read more

Emergency department (ED) physicians take potential head injuries seriously, perhaps too much so, according to a study in the American Journal of Roentgenology. Patients complaining of dizziness, syncope, or near-syncope too often get head CT scans, say researchers at the University of Hawaii and Kaiser Foundation Hospital. Fewer than 7.1% of 253 patients complaining of dizziness … Read more

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

Significantly more than 79,000 patients in numerous studies which randomly contrasted using vitamin D into some placebo within atleast a three-year time span of time. Haykal along with also his team found in on some other advice that entailed cancer occurrence and mortality. “The gap between the mortality rate between your vitamin and placebo groups … Read more

Call for Manuscripts Managed Care will soon begin to publish peer-reviewed articles of interest to the industry. Here are our guidelines. COVER STORY Direct Contracting: Why It Hasn’t Grown It sounds wonderful to managed care detractors: Why not let employers deal with providers without interference from HMOs? There are reasons why direct contracting doesn’t thrive. … Read more

The competency of physician groups is often as important as HMO performance in determining patient outcomes, California health regulators have decided. Officials are acting on the premise that patients who can’t switch their health insurer at will, can still shop around for the best physicians. The physician group ratings are included in a report card … Read more

Younger Women Too Often Ignore Signs of Heart Attack 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. They either don’t recognize more nuanced symptoms … Read more

It’s too easy to become jaded when you cover a beat. Too often on our beat — managed care — we are left facing the same problems year after year until it becomes a challenge to notice if anything has changed. “Will physicians ever buy into disease management?” “Can HMOs really offer more choice while … Read more

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

While the United States has been in turmoil over how to tame its excessive health care bill, the Brits have their own problems — different, but in some ways the same Robert Royce, PhD Back in 2000 I wrote an article for Managed Care (“Health Care Reform in the U.K.: Managed Care by Another Name”) … Read more

Blue Cross and Blue Shield of Minnesota and American Healthways score a hat trick by improving outcomes and satisfaction while saving money. Two years ago, Blue Cross and Blue Shield of Minnesota faced issues common among health plans. Its disease management programs had resulted in reasonable successes in controlling costs for diabetes and cardiovascular disease, … Read more

Also available in PDF ABSTRACT: Managed care is stuck in a vendor stage of health care industry evolution that is organized, primarily, to beat back costs through contracted discounts and utilization management. At the same time, the potential exists for an altogether different managed care that is based on a more explicit mission of lowering … Read more

If you thought a lot of time and money was spent on Y2K readiness, you ain’t seen nothin’ yet. Complying with the new rules for electronic transaction standards under the Health Insurance Portability and Accountability Act (HIPAA) is expected to exceed Y2K in terms of dollars and work hours. Some estimates peg the cost to … Read more

Physicians (and most others in health care) learn early that you need to remain somewhat emotionally detached from patients’ struggles if you want to render the best care. Clinical clear-sightedness is crucial. So maybe it was a case that Stephen Hauser, MD, was still too newly-minted when he treated a young woman 40 years ago … Read more

Most technological changes in publishing go on behind the scenes. A patient may find himself swallowing a new pill, or stretched out in some novel imaging machine, but a magazine reader sees the same magazine, more or less, that he saw years ago. New printing technologies, improved tools for designing pages, advances in how we … Read more

At the Eshelman School of Pharmacy, has deep consequences to the area of medication delivery using red blood cells to take medication and subsequently using light to discharge them at precise locations. The procedure, which modulates a decades-long scientific obstacle, could radically lower the quantity of a medication required to treat infection and so sideeffects. … Read more

Let’s conclude the first part of our look at how to negotiate fees in risk contracts. So far, we have explored a relatively easy way for a physician or medical group to identify a target capitation rate or global budget, and to ensure that the patients a managed care plan offers are compatible with your … Read more

A standard method of measuring patient adherence to medications would go a long way toward addressing this vexing health care problem, according to a study in the Journal of the American Pharmacists Association. The study “Targeting Cardiovascular Medication Adherence Interventions” states that “Adherence measures differed between studies both as an outcome and a means of … Read more

Lobbying state legislatures pays off for physician groups, and now health plans must provide more detail on who leases their networks John Carroll For almost a decade, the American Medical Association has set its sights on eliminating what it sees as a thorn in the sides of doctors around the country — one state at … Read more

These days, a few dollars’ difference in monthly premiums can cause companies or their employees to switch health plans. How do managed care organizations cope with the turnover phenomenon?   These days, a few dollars’ difference in monthly premiums can cause companies or their employees to switch health plans. How do managed care organizations cope … Read more

The verb “to satisfy,” in its various forms, is subject to a host of applications–some of them X-rated, of course, and some even sarcastic. I recall laughing at a line in the final episode of “The Dick Van Dyke Show” more than 30 years ago, in which sitcom regulars enacted a “High Noon” western spoof … Read more

Insurers and pharmaceutical companies want ICER to umpire debates about drug prices. But some question the cost-effectiveness calculations of the Boston not-for-profit and its dependence on QALYs. The Institute for Clinical and Economic Review (ICER), a small band of economists and health services researchers in Boston, is emerging as the nation’s go-to source for cost-effectiveness … 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

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

Although existing quality incentive programs related to physician services are limited to primary care physicians, a new survey describes non-primary care physicians’ views. Karen Murphy, PhD, president of Health Care Future Consulting, and David B. Nash, MD, chairman of the department of health policy at Jefferson Medical College, surveyed cardiologists, hematologists, oncologists, obstetricians, gynecologists, and … Read more

MANAGED CARE July 2008. ©MediMedia USA Employers have implemented a number of methods to slow down prescription drug costs, but waiving copayments for chronic conditions has yet to enjoy widespread use Martin Sipkoff Last year the cost of prescription drugs was the single largest part of health cost increases to employers, according to a recently released survey … Read more

The old TennCare program had many flaws and detractors. Its near collapse led to a more realistic approach to providing coverage to the uninsured in Tennessee. Full text in PDF TennCare is one of the most controversial Medicaid experiments in the recent history of state-level health care reform. Launched in 1994, this bold and ambitious … Read more

Will Your State’s Privacy Law Be Superseded by HIPAA? Careful interpretation required: Health plans operating in multiple states have a challenge sorting out where the federal law trumps state statutes. Hospital Copayments: At What Cost? High daily copayments for high-priced hospitals are coming into fashion. It’s all about shifting costs, but what about quality of … Read more

Afstyla, a brand new preventative remedy for hemophilia An improved in Korea, has got a permit from the Ministry of Food and Drug Safety. Afstyla is utilized for its prevention and suppression of hemorrhage, Regular avoidance of bleeding or decrease of bleeding regularity, and also prevention before and after operation. It isn’t utilized to cure … Read more

Certainly one of those Obesity-associated diabetes mellitus results in appreciable mortality, morbidity and large medical care expenses. In the united kingdom, obesity has been estimated to absorb 1.5percent of the NHS budget using an extra 10 percent of their funding allocated to diabetes care. In the united states, medical costs directly associated with diabetes complications … Read more

Some Builders’ Remorse: The Rise and Fall of the Oncology Medical Home Better outcomes and lower costs—in the long run. But payers were not impressed with the oncology medical home. Remodeling: Can the Oncology Care Model work when medical homes haven’t? In the end, it will be episode payment Keytruda Crosses First-Line Finish Line First … Read more

Health reform adds to employers’ cost, giving them the reason to bail out, and health reform will set up health exchanges, giving them a cost-effective exit strategy Thomas Reinke Health plans could find themselves between a rock and a hard place as health reform unfolds over the next few years. On one hand, employers may … Read more

A Harvard health economist and presidential campaign adviser says cost increases are on the right downward trajectory and will remain that way — as long as we keep pushing When David M. Cutler, PhD, predicted this spring in Health Affairs that a slowdown in health care cost increases could mean $770 billion in reduced spending … Read more

This population can benefit from Juxtapid and Kynamro, but the cost is not addressed by health reform I seldom am able to write about two different ground-breaking developments in medical technology in the same month. But research tends to happen in big jumps as a new receptor or biologic process is discovered; rapid determination of … Read more

Regulators fault patient-safety protocol Theranos Inc. has withdrawn its request for emergency clearance of a Zika virus blood test after the FDA found that the company didn’t include proper patient safeguards in a study of the new test, according to a report in the Wall Street Journal. The move is another black eye for the … Read more

Whilst the research Indicates on integrated care has evolved over the past Two years, so too has the important role leaders need for the execution, efficacy and longevity of healthcare. This paper investigates what it means to become the effective pioneer of healthcare sectors by drawing from the adventures of a management group in executing … Read more

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 17 KP-owned medical centers from 2004 to 2009 allowed … Read more

The Affordable Care Act sets a minimum medical loss ratio of 85 percent for health plans that participate in the large group market and 80 percent for the individual and small group market. Plans will have to get their administrative costs under control just to be able to keep premiums competitive, many experts believe. “Most … Read more

Good morning, cyberdocs: If you’re in Illinois and you contract with First Health Group PPO, you might want to spend a little more time answering patients’ E-mails. There’s gold in that keyboard.First Health Group says it will soon begin to pay physicians $25 for each clinical E-mail conversation with a patient, when it’s done over … Read more

July 31, 2018 Drugmaker Aiming for 25–30 New Drugs by 2022 Pfizer Inc. plans to increase research and development spending for the remainder of the year in an ambitious plan to accelerate the delivery of potential blockbuster treatments to market. The drugmaker raised projections for spending on research to $7.7 billion to $8.1 billion from … Read more

Bob Carlson 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 … Read more

Good luck getting it, because staying on regimens for these newer medications requires a degree of concentration not expected in the past As the TV commercial opens, a mature couple, holding hands and looking lovingly at each other, are walking in a woodland. They are smiling as the voiceover talks about the medication, adalimumab (Humira), … Read more

Sharing—that’s a good thing. And who can object to savings? So shared savings certainly doesn’t have an image problem, and it’s one of the most popular payment mechanisms in this fledging period of value-based health care. But winning popularity contests doesn’t mean you’re without flaws or critics, who are more than happy to point them … Read more

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

Some doctors say that far from cutting waste, online visits create it. Others are signing up and giving it a try. John Carroll Contributing Editor Roy Schoenberg spent a big part of January in Hawaii, but he wasn’t working on his tan. Schoenberg, a physician, was on a mission to boot up a health care … Read more

MANAGED CARE October 2010. ©MediMedia USA Although almost all businesses were touched by the slowdown, some weathered the recession better than others. In particular, large health insurers flush with cash had been buying up regional provider-owned plans — but that buying spree is slowing down, says A.M. Best, the credit rating company. The company says that in … Read more

News and Commentary Of the four models of personal health records (PHRs) that payers, providers, and health systems might be tempted to purchase, interoperable PHRs (i.e., those that are populated with data from all regional data sources via standards-based automated data exchange), may be the type that provides the best value for health plans and … Read more

Americans spent 34 percent more for specialty anti-inflammatory agents used to treat rheumatoid arthritis in 2005 than any other specialty drug category. The specialty anti-inflammatory class had the highest per-member per-year (PMPY) expense of all specialty classes, according to the Specialty Drug Trend Report from Express Scripts. The class, comprising four agents — Enbrel, Humira, … Read more

The current underwriting cycle is long in the tooth, but experts still see profitability ahead Ed Silverman The laws of physics make clear that what goes up must come down. But recent history suggests that the underwriting cycle for health insurance may prove to be an exception — we no longer know exactly when, or … Read more

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

There’s a low-key war going on between community pharmacies and the big guys that offer drugs by mail. Is this about money or medicine? Jean Lawrence Linda is a 51-year-old woman on maintenance estrogen and medication for hypertension. When she mentions the cost, her primary care physician suggests she try her HMO’s mail-order option and … Read more

Nights February 6thhe had been at an exceptional place to show a collection damaging stories concerning his superior, Bo Xilai: Bo’s familial relation into the supposed murder of British business man Neil Heywood, siphoning of Chongqing’s public capital, also shakedowns of local offender and also tri-ad elements. Up against the complexity of China’s leadership transition … Read more

Research says PA can help make treatments safer and more cost-effective, but data sharing must improve Health plans walk a fine line when it comes to requiring prior authorizations (PAs). Such rules can promote safe and cost-effective use of medications, but they can also be an administrative burden for everyone involved — doctors, pharmacists, PBMs, … Read more

West Virginia Gov. Cecil H. Underwood last month unveiled a disease management program to control Medicaid prescription drug costs. The governor chose the new program instead of a formulary, which a study group he appointed had proposed. The National Pharmaceutical Council, a not-for-profit organization funded by a group of drug manufacturers, will provide $500,000 for … Read more

Researchers Recommend Increased Testing for Men A recent study in JAMA Oncology found that U.S. women were more likely to get tested for inherited gene mutations associated with cancer risk, despite the fact that women and men who carry inherited BRCA gene mutations associated with increased cancer risk have an equal chance of passing them on to … Read more

Reform — Does It Just Mean More Regulation? No matter who wins the White House, clinical executives and other managers will need to deal with a shift in policy Insurer’s Obesity Program In N.C. Reduces Medical Cost Blue Cross & Blue Shield of North Carolina addresses social factor as way to managed population health It’s … Read more

The Food and Drug Administration approved avapritinib for adults Who Have unresectable or Efficacy has been researched in NAVIGATOR, a Multi Center, Single-arm, open-label trial registering 43 patients using GIST harboring a PDGFRA exon 18 mutation, for example 38 patients using PDGFRA D842V mutations. The trial initially registered patients at a starting dose of 400 … 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. Karen L. Trespacz 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 … Read more

Consumer directed health plans (CDHPs) deliver modestly better cost savings than non-CDHPs, according to the “Consumer-Driven Impact Study” by Milliman. When adjustments are made for typical risk and benefit factors, CDHPs produce 1.5 percent in savings beyond traditional plans. . . . WellPoint announced that it is launching the first real-time drug surveillance system that will monitor the … Read more

By Martin Sipkoff Contributing Editor The actor in the videotape speaks directly to the health plan member, who recently was diagnosed with coronary artery disease. The actor says that CAD is the most common cause of death in America: 12 million suffer from it, and 500,000 sufferers die every year. “Although choosing a treatment may … Read more

A retrospective analysis of claims data from Aetna indicates that systems that allow physicians to enter prescriptions electronically on a handheld device that also provides drug information and formulary status have no significant effect on compliance with formularies and utilization of generics. These systems were compared to traditional prescribing methods. Two study groups were compared: … Read more

Most health savings account (HSA) plans cover recommended preventive benefits on a first-dollar basis, which is to say without regard to whether the deductible has been met. America’s Health Insurance Plans surveyed its members to determine the preventive benefits provided by high-deductible health plans (HDHPs) that are compatible with HSAs. Results were published in the … Read more

Name Last modified Size Description Parent Directory 04-Jan-98 21:46 – 9706.comply.calendar…20-Jul-97 22:37 16k ../../archiveMC/9706/9706.comply.gif 11-Jul-97 02:19 13k 9706.comply.shtml 20-Jul-97 22:37 12k ../../archiveMC/9706/9706.compmon.left.gif 18-Jul-97 08:29 8k ../../archiveMC/9706/9706.compmon.right.gif 18-Jul-97 08:29 10k 9706.compmon.shtml 18-Jul-97 08:29 2k 9706.contents.shtml 20-Jul-97 22:37 5k 9706.disease_man.shtml 07-Jul-97 00:17 23k 9706.edge.shtml 26-Jun-97 02:56 11k 9706.editorsmemo.shtml 16-Jul-97 09:20 3k 9706.employer.shtml 08-Jul-97 02:51 7k 9706.ethics.shtml 25-Jun-97 … Read more

Without a change in course, middle- as well as low-income families might eventually be priced out of the health insurance market. If premiums for employer-sponsored insurance grow in each state at the projected national rate, then the average premium (constant dollars) for family coverage would rise from $12,298 (2008 average) to $23,842 by 2020 — … Read more

They say cleanliness is next to godliness. But as the outbreaks of carbapenem-resistant enterobacteriaceae linked to duodenoscopes illustrate, cleanliness in health care isn’t about the high moral ground. It’s about preventing harm, even death. Duodenoscopes are flexible endoscopes that can reach the pancreatic and biliary ducts, and they’re used to perform about 500,000 procedures each … Read more

Brand-name manufacturers and many neurologists see danger in generic substitution, but the FDA insists that the practice is safe In the war between brand-name drug companies and generics manufacturers, each side is almost religious in its orthodoxy and intransigence. The ground they fight over is the patient. On one side are the large pharmaceutical companies, … Read more

Tight budgets and an increasing influx of expensive biologic drugs make it imperative to rethink risk management John Marcille At a time when health care reform is uncertain and hard-to-categorize biological drugs are becoming a greater share of overall costs, health plan medical and pharmacy directors have the opportunity to help reinvent how health care … Read more

Color charts Also available as PDF One of the effects of managed care is greater responsibility for all participants in the health care industry — not just physicians. Hospital & Healthcare Compensation Service recently surveyed 195,410 employees of 381 hospitals in the nation to measure salary trends for nurse practitioners and physicians assistants for its … Read more

Last year, California Gov. Pete Wilson vetoed several managed care reform bills, saying he was waiting for a report from the Managed Health Care Improvement Task Force that he and the state legislature appointed. Now that the report and its 100 recommendations are in, the focus of reform moves back to the legislature. “Some will … Read more

These systems can improve quality, but in their present state of development, they can annoy physicians and are underutilized Tom Reinke Mrs. Jones, a 64 year old with diabetes, goes to her physician’s office for an upper respiratory infection. She has not been there for a few months. The doctor greets her and notes that … Read more

The rich ferment of ideas, opinions and causes in managed care today–a source of consternation to some, of stimulation to others–is evident throughout this issue. Senior editor Michael D. Dalzell, in our cover story, grapples with the issue of treatment protocols or guidelines. Gradually, physicians are coming to terms with guidelines, though of course they see … Read more

There are few issues that unite the political polarities these day, but there seems to be consensus emerging about this: We dump too many people in prison, including dumping them on a former coal ash landfill, a situation sparking controversy in a corner of Pennsylvania. Liberals might see overpopulated prisons as resulting from, say, police … Read more

Improvements in the features of diabetes pumps have evolved since their original backpack-size days. Managed care needs to evaluate the new bells and whistles. Short of a cure that involves a transplant or other unexpected breakthrough, the quest for the Holy Grail of diabetes management continues to be the creation of a continuous insulin delivery … Read more

The goal of diabetes management is maintaining glycemic control while targeting quality of life improvements Fadia T. Shaya, PhD, MPH Gaurav Deshpande, PharmD, MA MANAGED CARE May 2006. ©MediMedia USA The goal of diabetes management is maintaining glycemic control while targeting quality of life improvements Fadia T. Shaya, PhD, MPH Gaurav Deshpande, PharmD, MA Overwhelming recommendations from … Read more

Medicaid growth nations climbed in 2014 to 2016 but diminished in Medicaid expansion nations. Mean gap in infant mortality rate in Medicaid growth versus non–Medicaid growth states climbed from 0.573 at 2014 into 0.838 at 2016 due to smaller declines in non–Medicaid growth than at Medicaid growth states. The 14.5% infant mortality rate decrease from … Read more

The internationally known health care economist says we have been heading in the right direction all along — we just have to tackle problems in the right order Health care economist Uwe E. Reinhardt, PhD, is bullish on health care. The decline in the growth of health care costs looks as if it is permanent, … Read more

By Paul Wynn Associate Editor For a moment, imagine health care providers as the members of a big-city orchestra. Primary care physicians, specialists, nurses and pharmacists don formal wear and hoist instruments to entertain concertgoers. When the conductor waves his baton, is the sound harmonious? It wouldn’t be, if the orchestra followed medicine’s traditional pattern. … Read more

Officials at the Centers for Medicare & Medicaid Services don’t like the idea, but Congress makes the rules (unless the president vetoes them) Martin Sipkoff Next year’s Medicare Part D offerings contain the seeds of significant future change. No doubt unhappily for consumers, more than three fourths of the plans carry premium increases. Unhappily for … Read more

A reaction to the proposition has varied. And pharmacy benefit managers say it is the medication manufacturers that establish the costs, also it’s really hard to not point the blame in pharmaceutical businesses as prices for antipsychotic drugs to treat rare diseases have some times risen by tens of thousands of dollars, even for no … Read more

By E. Loren Buhle Jr., Ph.D. Organizations establishing “dot.com” operations on the Internet are Wall Street’s darlings, offering the lure of large profits when the organization goes public. This presumes that online operations will supercharge their markets — and investors’ pocketbooks. While online organizations are truly changing the commercial landscape, online drugstores have many issues … Read more

Michael S. Victoroff, M.D. November’s Nature Neuroscience reports the case of a British fellow with a brain injury who had lost the ability to feel disgust. Neuroscientists at the MRC Cognition and Brain Sciences Unit, in Cambridge, presented the 25-year-old stroke victim with pictures of disgusting things, and other stimuli don’t bear describing in detail. … Read more

I expect the next 10 years of policy debates, action, and inaction concerning how to curb our obesity epidemic to be an accelerated version of the last 30 years of public policy related to fighting tobacco. This week’s HBO documentary, The Weight of the Nation, landed a flourish of solid blows against the wrong-headed notion that … Read more

Health plans are devising ways to function even when their providers are being overrun and the insurers themselves face a vastly depleted workforce Ed Silverman To cope with the possibility of an avian flu pandemic, Blue Cross Blue Shield of Minnesota expects many of its 2.7 million members to seek health care out of the … Read more

The Disease Management Association of America (which now calls itself DMAA: The Care Continuum Alliance) has issued the second volume of the “Outcomes Guidelines Report.” The original report sought to develop the correct way to calculate the return on investment of disease management programs. Volume 2 updates the previous version by adding new clinical measures, … Read more

Joyce Ochs Despite the technological advances of the past decade, a Star Trek world is still in the future for most of us. On the other hand, physicians today are writing prescriptions for patients on palm-held devices that seem eerily akin to medical practice on the Starship Enterprise. Hand-held computing devices are hot technology in … Read more

The end point of reform may be physicians and patients gaining some power at payors’ expense. But for patients, a place at the table requires greater self-responsibility. THE FACULTY Philip R. Boulter, M.D., Senior Vice President and Chief Medical Officer, Tufts Health Plan John K. Gorman, President, Managed Care Compliance Solutions William F. Jessee, M.D., President and CEO, … 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

The Authoritative Disentanglement Consistence Act (ASCA) necessitates that Federal health care claims be sent electronically except if certain special cases are met. Suppliers meeting an ASCA special case may send their cases to Government health care on a paper guarantee structure. (For more data with respect to ASCA exemptions, allude to Part 24.) Suppliers sending … Read more

Jeffrey J. Denning Every worker needs a performance review at least once a year. So, who reviews the reviewer? You do. MANAGED CARE November 2000. ©2000 MediMedia USA Every worker needs a performance review at least once a year. So, who reviews the reviewer? You do. Jeffrey J. Denning Every practice has someone in charge. It may … Read more

Increases in both retail and mail copayments for generics, preferred brands, and nonpreferred brands are on the rise, with members paying a greater percentage of retail costs than of mail-service costs, according to the Pharmacy Benefit Management Institute’s Prescription Drug Benefit Cost and Plan Design Report. The report captured copayment and coinsurance amounts for retail … Read more

Fixing substitution, understood as well as medication changing and healing inter change, could be the custom of substituting someone’s prescribed medication using clinically different medication which can be predicted to possess the exact clinical result. Some occasions patients change into an alternative medication without the issues. But for sure ailments and medications, therapeutic substitution can … Read more

Senate Democrats on Thursday demanded a ethics research to Tom Price,” presidentelect donald-trump’s choice for U.S. healthcare secretary, after a written report which the ferocious Obamacare politician traded in healthcare stocks while driving laws in Congress which can impact those stocks. Senate Democratic pioneer Chuck Schumer and many others left their remarks as diplomatic Republicans … Read more

A peripheral attraction amid the thrills of this year’s election was Maine voters’ rejection of a bill legalizing physician-assisted suicide. Oregon remains the only state where this is sanctioned. Proposals for “physician assistance in dying” will surely come before other legislatures over the next few years, however. Up to now, these have tended to follow … Read more

Cancer is an socio-economical burden in virtually any state. Out of the, breast feeding is regarded as probably the most prevalent malignancy worldwide among women regardless of era. As women are still an essential part in a community, the use of these potency supporting the evolution of a state is a important problem in every … Read more

More and more health plans are being told that they need to do good if they want to do well. Is this fair? Are other industries forced to make charitable donations? John Carroll Early in January, Michael Merson, the chairman of CareFirst BlueCross BlueShield, went to the Maryland Legislature with a proposal. He had a … Read more

CAR-T treatments are all the rage and showing some remarkable results. But the high price, along with the lack of long-term results, quiets the optimism. Navneet Majhail, MD, seldom sees medical developments as game changing. After all, medical progress tends to be a game of inching forward, not rewriting the rules. But the director of … Read more

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

As health plans and other organizations refine criteria for the practice, consumer advocates voice some concerns.   When Health Plan of Nevada first told physicians to prescribe double-strength tablets of three medications so that members could split the pills before taking them to cut costs, some vocal consumers objected to the move. The HMO’s public … Read more

Dwindling market share, rising costs, and a drastic drop in investment income buffet the health insurance industry Frank Diamond Managing Editor It’s not recession-proof. The managed care industry never really was recession-proof. The health care industry as a whole has always been considered recession-proof, says John Fitzgibbon, the national segment leader for health care payers … Read more

A longtime advocate is still betting on a single payer system because, she says, the new reform law won’t come near to doing what’s needed All of the talk about health care reform has been a little like debating whether to “give a cancer patient Tylenol or aspirin when the person needs a surgeon,” says … Read more

How electronic health records, in their many manifestations, will transform health care should be evident within a couple of years. Will the potential be realized? Martin Sipkoff Contributing Editor Seventeen years ago, David W. Bates of Brigham & Women’s Hospital in Boston and Lucian Leape, MD, of the Harvard School of Public Health, with others, … Read more

Value-based Maintenance payment models that Dedicated to a world wide funding home runs at a current Trump administration inspection, however bundled payment results were much mixed. Brad Smith, the mind of the Center for Medicare & Medicaid Innovation hat oversees healthcare payment models, offered throughout the National Association of Accountable Care businesses’ fall seminar Tuesday … Read more

Follow this link to PDF version An Industry Matures National HMO enrollment fell by 400,000 last year, from its all-time high of 81.3 million. For at least two years, a wider array of managed care products, such as point-of-service plans and PPOs, and an ever-smaller pool of people still covered under indemnity plans slowed the … Read more

MANAGED CARE October 2010. ©MediMedia USA A consultant urges plans to streamline Web sites and devise new contracting strategies to prepare for an influx of individual customers Health care reform will lead individuals to purchase their own coverage in greater numbers than the Congressional Budget Office predicts, and that will mean major changes and new opportunities for … Read more

Funding shortfalls or blatant bankruptcy loom for its retirement programs because requirement develops from a aging people. A mortal pandemic and fighting market have just hastened demographic and fiscal pressures. In 2021, Social Security is anticipated to start drawing down its trust fund to pay benefits rather than tapping just the attention. Unless Congress acts, … Read more

This new code set promises to delineate like never before the type of physician service rendered Look to the blue horizon and behold the biggest systemic and technological challenge in generations. The implementation of ICD-10 codes will change forever the way medical directors, hospital officials, physicians, and everybody else in health care conducts business. It’s … Read more

In May, the American Society of Clinical Oncology (ASCO) released a proposal to significantly improve the quality and affordability of care for cancer patients. Expanding on a payment model circulated last year, ASCO’s proposal would fundamentally restructure the way oncologists are paid for cancer care by providing sufficient payment to support the full range of … Read more

Health plans, with their view of the complete spectrum of patient care, are in a unique position to identify problems with polypharmacy Managed care companies are increasingly developing systems for closely monitoring polypharmacy. Physician notification and education remain the most effective way to reduce polypharmacy. And the two most common techniques — medication reviews and … Read more

Despite having the costliest health care system in the world, the United States ranks last compared with five other affluent countries on measures of quality, access, efficiency, equity, and outcomes, according to a Commonwealth Fund report that analyzes international health policy surveys. The United States did do well on some preventive care measures. “The United … Read more

The Health Care Financing Administration has issued proposed rules on payment for physicians and other providers, such as nurse practitioners, clinical nurse specialists and clinical social workers, for teleconsultations under Medicare. Under the proposed regulations, teleconsultation is considered a new way or process of delivering a consultation, not a new medical service. Therefore, according to … Read more

BY NEIL CAESAR, J.D. The ability of a physician or medical group to determine an affordable fee payment level is a cornerstone of effective managed care contract negotiation. Last month, we focused on an easy way for a practice to identify its current profit margin for clinical services. From this information, the effect of managed … 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

There are many genetic mutations attributable to the condition, but Kalydeco can significantly help a specific subpopulation of patients Thomas Morrow, MD I can still remember the anguish on the faces of parents whose children were being treated for cystic fibrosis (CF) during my training at a children’s hospital in the late 1970s. They knew … Read more

Recession-minded regulators don’t like this year’s proposed rate hikes. Just try telling them that the increases are based on actual rising costs. John Carroll As president of the Retailers Association of Massachusetts, Jon Hurst hears a lot from small-business owners these days about the cost of health care insurance. Under a Massachusetts mandate, employers have … Read more

Agency cites insufficient efficacy data The FDA has issued a complete response letter to the new drug application (NDA) for drisapersen (Kyndrisa, BioMarin Pharmaceutical Inc.) for the treatment of patients with Duchenne muscular dystrophy amenable to exon 51 skipping. The FDA issues complete response letters to indicate that an application is not ready for approval … Read more

By John La Puma, M.D. An exchange of letters in the Journal of the American Medical Association last year titled “Physician Marketing of Nutritional Supplements” revealed that some physicians have qualms about selling supplements in, from, and out of the office. Managed care should have a special interest in sales of supplements in the office, … Read more

‘Pharmatization’ might save health plans money. There are four major reasons to make the move — but also reasons to go slow. Specialty drugs have been a house divided. Oral medications have been managed under the pharmacy benefit while medications that are infused or injected have been managed as a medical benefit. Self-injected medications have … Read more

Recession-minded regulators don’t like this year’s proposed rate hikes. Just try telling them that the increases are based on actual rising costs. John Carroll As president of the Retailers Association of Massachusetts, Jon Hurst hears a lot from small-business owners these days about the cost of health care insurance. Under a Massachusetts mandate, employers have … Read more

Cost increases for health services should lessen for both employers and the health insurance plans that serve them in 2008, according to two major consulting companies. Employers can expect to see single-digit increases in what it costs to provide coverage to their workers next year, according to a study by PricewaterhouseCoopers. Findings are based on … Read more

Employers, DM Vendors Edging Just a Bit Closer 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 Does Supreme Court’s Tilt Portend Problems for HMOs? The Rehnquist Court is decidedly pro-states, as are many lower-level judges, … Read more

A broad consortium of players joins with the NCQA to shine a light on the drugstore With an average of 12 prescriptions per person in 2008, consumers may have more contact with their corner pharmacy than with any other part of the health care system, but in many ways pharmacies are a black box. “Transparency … Read more

BY JOHN A. MARCILLE   Every state in the country is responding to the managed care backlash. From Bismarck to Baton Rouge, aspiring state senators are lapping it up, saving their best populist oration for that big, bad — and anonymous — creature, managed care. In good times, easy targets are elusive and like gold. … Read more

Patients are responding to online programs that help them improve or maintain their health and become better consumers Health insurers face ever-changing expectations from their primary customers — employers — and one challenge that has been tough to meet is getting consumer buy-in on wellness and health promotion. In some cases, employers go around their … Read more

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

Type Title Author Story Seeking Headquarters Quality In a Branch-Office Town webadmin Story Medical Directors Cast Wary Eye On Cost of Biologics webadmin Story Government To Pay New York Hospitals $400 Million To Trim Residencies webadmin Story Three New England States Form Drug-Buying Cooperative webadmin Story Headlines On Deadline… webadmin Story Feds Extend Deadline To Use … Read more

Approval decision set for July 21 Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence, has allotted only five hours, or half a day, to the breast cancer drug neratinib (Puma Biotechnology) at an advisory committee meeting scheduled for May 24, according to a report posted on the financial news website The Street. … Read more

Back in 2006 with the passage of the Tax Relief and Health Care Act, Centers for Medicare & Medicaid Services (CMS) was charged with establishing a physician quality reporting system that would include incentive payments to eligible providers. This Physician Quality Reporting Initiative (PQRI) initially targeted individual providers, but in 2010, group practices may also … Read more

Smaller HMOs and insurers more likely to be affected The headlines suggest that the worst is yet to come. When Eliot Spitzer, the New York attorney general, recently disclosed an investigation into alleged rigged insurance bids by Marsh & McLennan, investors reacted with anxiety. Initial reports focused on major brokers and insurers of commercial lines. … Read more

Many health care organizations that had reached for the brass ring are now wringing their hands as they file for Chapter 11. All is not lost, however. By Keith J. Shapiro and Nancy A. Peterman Sidebar: Plans with problems Managed care transformed not only the way that our health care system works, but also the … Read more

Dwindling market share, rising costs, and a drastic drop in investment income buffet the health insurance industry Managing Editor It’s not recession-proof. The managed care industry never really was recession-proof. The health care industry as a whole has always been considered recession-proof, says John Fitzgibbon, the national segment leader for health care payers at the … Read more

Not quite. In a politically driven system of management, the inevitable result was that market forces were ignored — to disastrous effect. STAFFORD, ENGLAND — The experience of health care reform in the U.K.’s National Health System should, if nothing else, help to illuminate (for Americans who are disillusioned with their own system) that pitfalls … Read more

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

A CONVERSATION WITH JOHN M. EISENBERG, M.D., M.B.A. New name — Agency for Healthcare Research and Quality — new focus. The director says it’s less about guidelines, more about preventing errors. As director of the federal Agency for Healthcare Research and Quality, John M. Eisenberg, M.D., M.B.A., is the point man in the federal government’s … Read more

While a few independent physician-owned HMOs are winning some attention, ownership by national managed care companies accounts for a growing majority of the country’s HMO enrollment, according to a recent statistical report. The figures below apply to “pure” or traditional enrollment as opposed to “open-ended” enrollment, which allows members some reimbursement for services by providers … Read more

Parkinson’s disease will be the most popular celiac disorder, on average agreeing using a feature movement disease, composed of bradykinesia, rigidity, remainder tremor and postural disturbance. Extra non-motor indicators happen, for example depression, stress, sleep abnormalities, irritability as well as cognitive drop together with dementia, which may greatly impair the individual’s wellbeing. Dopaminergic reduction additionally … Read more

Of the 3.3 million low-income beneficiaries who have Medicare Part D coverage, 65 percent (2.2 million) will have to choose a new plan in 2010 or face paying a premium if they decide to remain in their current plan, according to a recent Henry J. Kaiser Family Foundation report, “Part D Plan Availability in 2010 … Read more

“What do you want from me? Blood?” So goes the oft-thought but rarely voiced employee complaint. Well, more employers have actually begun taking employee blood to integrate biometric information into wellness programs by measuring such things as cholesterol and body mass index.“ Nine percent of large firms that ask employees to complete a health risk … Read more

Employers and health plans are starting to see the advantage of what has been termed evidence-based benefit design Slowly but surely, the idea that improved quality of care means lower care costs is permeating our health system. “Resistance to that idea is not like it once was,” says Brent James, MD, executive director of the … Read more

Poor marketing and lack of a pre-existing condition clause opened the gates to patients who got specific services and then left. Once upon a time, an independent practice association lost $4 million in a single year because of poor payer marketing practices and misplaced trust ….” This is a story as gruesome as any fairy … Read more

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

She’s a nurse board certified in preventive medicine and community health. The expression health equity describes patients with”a good and just opportunity to become healthy as you possibly can ” The expression is connected to societal determinants of health, the concept which challenges like discrimination, poverty, lack of access to tasks, wholesome meals, quality home, … Read more

Profits should increase over the next two years for plans that stay the course, but politics and rising premiums may affect long-term results A congressional report estimates profits for the 12 largest Medicare Part D plans to be about $1 billion in 2007, although some analysts say that figure is too high. The report estimates … Read more

Insured patients are liable for ever greater out-of-pocket payments, and providers will have to evaluate their creditworthiness and act accordingly Consumers have demonstrated a strong preference for low-cost premium plans that feature high cost sharing. At the same time, there has been little effort to qualify or quantify a patient’s ability to meet the increased … Read more

The good times rolled on for the nation’s HMOs in 2003, according to Weiss Ratings. The industry nearly doubled its profits, earning $10.2 billion, an 86 percent increase from the $5.5 billion it earned in 2002. Kaiser Foundation Health Plan was the big winner, reporting a $1.1 billion increase in earnings. That is about one-fifth … Read more

Because it enables both the security and sharing of data, blockchain seems ideally suited to health care. Next year, the pieces may come together for it to finally get some real traction in the sector. Blockchain is one of those curiosities like Picasso’s cubism: People admire it but don’t know what to make of it. … Read more

Peer-viewed studies and review articles on managed care. ORIGINAL RESEARCH Cost Effectiveness of the Insertion of Hydrogel Spacer in Men Treated With Radiation Therapy for Prostate Cancer ABSTRACT  Purpose: The study examined the cost effectiveness of prostate cancer radiotherapy with and without the use of a hydrogel spacer. Design and Methodology: Retrospective data from Truven … Read more

Current pay-for-performance programs apply only to a handful of diseases. If we don’t pay for all the other diseases, will they get short shrift? Current pay-for-performance programs apply only to a handful of diseases. If we don’t pay for all the other diseases, will they get short shrift? I am uncertain about so-called “pay for … Read more

The idea is radical and simple: Those who need medication the most should pay the least. There is evidence that this is cost-effective. The benefit-based copayment model, which places individual consumers with established medical need on the lowest formulary tier, is a simple and humane concept: Keep chronically sick people from needing expensive care by … Read more

Wellness Debate Irrelevant For Insurers Eyeing the Market Last year’s fiasco at Penn State represents just one crack in the wellness armor. Worker resentment rises as experts begin to question the effectiveness of such programs. But employers still believe and so long as there are buyers, there will be sellers. Continue reading… NEWS & COMMENTARY … Read more

Despite all the smoking-cessation efforts and the countless warnings by all the surgeons general, medical costs for chronic obstructive pulmonary disease (COPD) are expected to skyrocket by 2020, according to a study by the Centers for Disease Control and Prevention that was published in the journal Chest. Direct and indirect costs will rise from about … Read more

Naturally, doctors are more likely to buy into a physician-led DM program. Rewarding them for resulting lower medical costs keeps them in the game. MargaretAnn Cross For a listing of other articles in this series, see end of article If a patient whose physician works for Harvard Vanguard Medical Associates ends up in a hospital … Read more

For many, HIV/AIDS can now be a chronic, not necessarily fatal, disease. But some plans don’t provide optimum drug therapy and care by experts. Anthony J. Kemper has been HIV-positive for 10 years. During that time, he has seen his condition transformed from a virtual death sentence to a manageable disorder. “I had some scary … Read more

Treatment approved for post-HSCT maintenance in multiple myeloma patients The FDA has expanded the existing indications for lenalidomide (Revlimid, Celegen Corporation), a thalidomide analogue, to include use in patients with multiple myeloma as maintenance therapy after autologous hematopoietic stem-cell transplant (auto-HSCT). The expanded indication makes lenalidomide the only treatment to receive FDA approval for maintenance … Read more

Mostly it is self-insured employers that are offering the option, but health plans may well want to join in Surgery is scary, and no matter what the surgeon’s qualifications or bedside manner, most patients worry in the days preceding it. The ride to the hospital seems all too brief. However, an increasing number of patients … Read more

His wife was scared and in pain. Emergency surgery was imminent. Yet the aide at her bedside persisted. “I said, do you have any allergies?” the aide asked for the third time. “I felt like saying, ‘Can’t you just go look in the computer?’” recalls John A. Page, executive director of the Healthcare Information and … Read more

MANAGED CARE March 2010. ©MediMedia USA Following evidence-based care treatment protocols resulted in a 35 percent cost savings for patients with non-small-cell lung cancer (NSCLC), according to a study conducted by Aetna and U.S. Oncology, a cancer research and care network. The study compared patients treated using evidence-based guidelines (on pathway) to those treated using non-evidence-based guidelines … Read more

Experts, including many health plan medical directors, agree: We have a long way to go. It’s essential rhetoric for both political parties that America has the best health care in the world. Bill Clinton said so when he was president and George W. Bush says so today. Republican Senate Majority Leader Bill Frist says we … Read more

Plagued by higher costs and the need to provide at least bare bones coverage, more companies, and smaller ones, are self-insuring. Three years ago, Tammy Carr could offer her employees at Arco Concrete an “HMO rich” policy of health benefits. Copayments were low, the cost to the company was about $100 per worker each month, … 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

An analysis of HMO payment systems reveals remarkable uniformity, regardless of market size. Capitation is HMOs’ favored method of reimbursement for primary care physicians, while discounted fee for service is the primary order of business for HMOs when contracting with specialists. Whether the market size is 2 million or 200,000, the share of primary care … Read more

David Lansky, Ph.D., has served as president of FACCT — the Foundation for Accountability — since the not-for-profit organization was created three years ago. FACCT defines its mission as helping consumers make better health care decisions. Paul Ellwood and other members of the Jackson Hole Group pushed for the group’s creation to help assure that … Read more

The Disease Management Association of America (which now calls itself DMAA: The Care Continuum Alliance) has issued the second volume of the “Outcomes Guidelines Report.” The original report sought to develop the correct way to calculate the return on investment of disease management programs. Volume 2 updates the previous version by adding new clinical measures, … Read more

Hospitals are hyping better outcomes with the robot, but economics and marketing may be driving the push With three hospitals and 311 beds in small cities in south central Ohio, Adena Health System is not exactly a major metropolitan medical center. But its website does herald Adena Health as the only provider in its region … Read more

Medications that lower cholesterol and manage diabetes account for $38.1 billion — the single largest category Martin Sipkoff A recent analysis by the federal Agency for Healthcare Research and Quality (AHRQ) of the spending patterns of adult Americans on prescription drugs found that in 2006, medications affecting metabolism, accounted for $38.1 billion — the single … Read more

Physician practices that offer night and weekend hours keep costs down without adversely affecting mortality rates, according to a study in the Annals of Family Medicine. The study — “Extended Office Hours and Health Care Expenditures: A National Study” — says that “Extended access may thus represent a marker of primary care practices with a … Read more

Authors finds 63% increase in risk compared with other antidiabetic treatments The diabetes drug pioglitazone (Actos, Takeda Pharmaceuticals) is associated with an increased risk of bladder cancer, according to a study published in the British Medical Journal. The findings suggest that the risk increases with increasing duration of use and dose. No increased risk was seen for … Read more

Could avian flu give rise to a pandemic that might rival the fearsome Spanish flu? Is the nation – let alone any individual MCO – ready? Jack McCain Contributing Editor These days, the phrase “blue flu” usually is applied to walkouts by police officers, but it just as readily could be used to describe the … Read more

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. SOURCE: STATELINE, SCOTT-LEVIN GOVERNMENT AFFAIRS, NEWTOWN, PA., 1998 … Read more

Training left physicians unprepared for market-based medicine. Doctors can compete by understanding forces that determine any industry’s profitability. Mark R. Vanelli, M.D., M.B.A. In times past, medicine was Camelot and physicians its kings. No longer. While American medical training is generally regarded as the best in the world, it was not conceived with the idea … Read more

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

Texas Health Resources, the parent company of Harris Methodist Health Plan, has agreed to unload its money-losing HMO to Blue Cross and Blue Shield of Texas. The Blues will buy a majority stake in Harris Methodist, though the purchase price has yet to be determined. Disposing of Harris Methodist, the largest HMO in northern Texas … Read more

Companies are decreasing their share of premiums. It remains to be seen how this will affect workers’ health status. Pogo’s observation, “We have met the enemy, and he is us,” seems true about the crusade to control health care cost. It’s a Herculean battle with ourselves. Hercules fought the shape-shifting Proteus, whose own form was … Read more

Flush with successes from recent efforts to sniff out Medicare fraud and abuse, the Department of Health and Human Services has launched the next phase of its antifraud campaign. HHS will begin hiring anti-fraud contractors, following a 60-day public comment period. Contractors will have liberty to review provider records for medical necessity of claims; cost … Read more

Washington Initiatives The Medicare+Choice program is getting out of the gate rather slowly. At press time, the Health Care Financing Administration had received only two applications from groups wanting to establish provider-service organizations and one from a prospective preferred-provider organization — and none at all from insurers offering medical savings accounts. What’s the problem? According … Read more

Aviation’s ever-increasing competition and client sophistication have attracted businesses’ focus on plans. Aiming not just to transcend your contest but and to captivate clients, air companies are searching for responses in the the offline and online world. Researching on the web chances is one of the utmost truly effective techniques to interact to viewers. Diving … Read more

Supply meeting demand isn’t always good. We watched for years as young doctors displayed less and less interest in primary care. They’re only human, after all. An income difference between primary care physicians and specialists that can be measured in hundreds of thousands of dollars is difficult to ignore. That’s why the point made by Barbara … Read more

Health plans and providers got what they wanted from Congress for the new year: passage of the Medicare, Medicaid, and Balanced Budget Refinement Act of 1999. But for Medicare+Choice plans, is it the gift that will keep on giving? Some inside-the-beltway experts say the new law isn’t the panacea it appears to be at first … Read more

Impossible-to-enforce mandates won’t work. Pharmacy directors and others must pose the right questions to the right people. Arthur Lazarus, MD, MBA Full and accurate disclosure of conflicts by researchers does not ensure the prevention of publication of articles that are misleading or otherwise biased. In the book On the Take: How Medicine’s Complicity With Big … Read more

A subsidiary of Aetna U.S. Healthcare is the first HMO to face a malpractice lawsuit under a recently enacted Texas law. The suit against NYLCare of Texas was filed by the family of a 68-year-old Fort Worth man who committed suicide by drinking antifreeze hours after being discharged from a psychiatric hospital over his physician’s … Read more

From the SGLT2 course of meds to deal with diabetes, CVS eliminated That is in spite of the fact Invokana was included by having a heightened risk for amputations at a cardio vascular effects study completed before this past season. Both meds published A14% reduction lowering of CV threats inside their various outcomes . Composed … Read more

Scientists at The Australian Public College have tracked down an essential stockpile course that disease cells use to get their supplements, in a revelation that could prompt new medicines to stop the development of tumors. The exploration group hindered passages through which the malignant growth cell was acquiring the amino corrosive glutamine and discovered the … Read more

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

When biologics go off-patent, copycat products could lower oncology expenditures by the millions, if not billions. But the discounts and future market share are far from certain. In a classic Dick Van Dyke Show episode, the late Mary Tyler Moore accidentally gets her big toe trapped in a hotel bathtub faucet spout, and the elderly handyman summoned … Read more

The average copayment for preferred brands has cracked the $14 mark, while third-tier copayments average near $30. Four of every five health plans offer a three-tier benefit. SOURCE: SPRING 2000 MANAGED CARE FORMULARY DRUG AUDIT, SCOTT-LEVIN, NEWTOWN, PA.

Where Everybody Knows Your Name (if you are a medical director) Back in the 1980s, the theme song for the television comedy show Cheers had a line: “Where everybody knows your name and they’re always glad you came.” Now, clinical executives have that place, and its drawing power is not the broad strokes associated with a mammoth … Read more

Paul Terry Though the Department of Health and Human Services and Department of Labor issued final regulations concerning “Incentives for Nondiscriminatory Wellness Programs in Group Health Plans,”1 employers and health plans must still navigate unresolved inconsistencies between the Affordable Care Act (ACA) and the Americans with Disabilities Act (ADA). The latest ACA rules indicate that if … Read more

Access to Celebrex and Vioxx under HMO drug formularies has increased about 50 percent over the past two years, according to data from MediMedia Information Technologies’ Formulary Compass. Access (defined here as having a status of first tier, second tier, prior authorization or on formulary, but not third tier) to Celebrex increased from approximately 45 … Read more

As recommended treatment grows more aggressive, health plans should better manage both infusion and injectable medications There’s a lesson for health plans in the way treatment of rheumatoid arthritis (RA) is changing. “The trend today is to try to attain complete remission,” says Patience White, MD, a practicing rheumatologist and vice president at the Arthritis … Read more

Insurer tie-ups are nothing new. But there’s been a shopping spree lately as uncertainty about the ACA recedes, providers bulk up, and government payers become more important. It got started just as the dust was settling after the Supreme Court’s momentous King v. Burwell decision in June that effectively kept the ACA intact. First up … Read more

MANAGED CARE November 2004. ©MediMedia USA The issue is how extensive the list of covered medications should be for the new Medicare pharmaceutical benefit. The stakes are enormous. John Carroll The United States Pharmacopeia isn’t what you’d consider a controversial organization. But when Congress selected USP to develop a model drug formulary that could be adopted by … Read more

High quality post-hospital orders can cut readmissions by 30 percent. Medical administrators may soon insist on it. Tony Berberabe Patients who have a clear understanding of their after-hospital care instructions, including how to take their medications and when to make follow-up appointments, are 30 percent less likely to be readmitted or to revisit the emergency … Read more

Monoclonal antibody binds to PD-L1 protein   October 19, 2016   The FDA has approved atezolizumab (Tecentriq, Genentech/Roche) for the treatment of patients with metastatic non–small-cell lung cancer (NSCLC) who have disease progression during or after platinum-containing chemotherapy and have progressed on an appropriate FDA-approved targeted therapy if their tumor has EGFR or ALK gene … Read more

Annually sees that a few nine new medication licensed for usage, however in their wake there’ll soon be thousands and thousands of candidate medication which dropped by the wayside. The development and research travel of the new drugs which make it to promote will probably have obtained approximately 1-2 decades and cost approximately #1.15bn. The … Read more

Reach a bargain to replace the Affordable Care Act as it returns in the recess next week, even at a crude assessment of the party’s healthcare prospects. “It is improbable that we’ll find yourself a healthcare bargain,” Mr. Burr told WXII 12 News, a Vermont news channel, on Thursday. He explained the House-passed GOP health … Read more

Advanced therapy management may lead to physician acceptance of additional medications infused at home Home infusion has been around for over 30 years, but it is a service that has never really taken off. Effective infusion drugs have been developed for acute conditions, but home infusion has been relegated to less glamorous uses such as … Read more

Over The last decade, clinical tests have become a common component of clinical exercise. Every single day, clinical conclusions at the bed side, rules of surgery at hospitals and practices, and wellbeing by authorities and carriers will be now being influenced by tips. They can provide succinct directions which screening or diagnostic tests to dictate, … Read more

Formal committee review set for July 19     A preliminary analysis by FDA staff has found that a potential risk of suicide with the investigational psoriasis medication brodalumab (Siliq, Valeant Pharmaceuticals) is challenging to assess because of limited data, according to a Reuters report. The review precedes a July 19 meeting of the FDA’s … Read more

An analysis in the New England Journal of Medicine (http://bit.ly/c2keSV (link is external)) February 18 about how the Dartmouth Atlas of Health Care rates hospitals has caught many eyes. Peter S. Bach, MD, a physician at Memorial Sloan-Kettering Cancer Center, posits that the Atlas uses flawed methodologies in suggesting that less is more. Dartmouth Atlas … Read more

Clinical Brief: Safety of Lipid-Lowering Therapies Download supplement This Brief summarizes four studies that examine the safety of HMG-CoA reductase inhibitors (statins). It also includes an analysis for MCOs by Steven R. Peskin, MD, MBA. Highlights: The Report of the National Lipid Association Statin Safety Task Force International Studies on the Comparative Safety of Rosuvastatin … Read more

Voters rated healthcare as the most important dilemma, supporting the market, terrorism and the war in Iraq,” in accordance with a different Washington Post/ABC News survey , Long Island Newsday reports. Researchers surveyed 1,202 people in July by exactly what they believed to be probably the most essential issue at the coming 2004 election, and … Read more

Two months after Harris Methodist Health Plan agreed to be acquired by Blue Cross and Blue Shield of Texas, the deal collapsed. Talks to close the $100 million sale dragged on so long, Harris decided to look for another suitor. Also in Texas, Aetna will dump its NYLCare units in Dallas and Houston, neutralizing regulators’ … Read more

Two Blue Cross plans in Pennsylvania are regrouping after separate legal actions. In Philadelphia, Independence Blue Cross has been ordered to stop a contracting practice that competitors said gave it an unfair advantage, and that hospitals complained hurt their bottom lines. The state insurance department told Independence it could no longer write “prudent buyer” clauses … Read more

Prescriptions for generic drugs rose sharply from 2008 and 2009, with generics jumping from 52.4 percent to 57 percent of all prescriptions. The sharp rise is linked to any number of factors, including the sluggish economy, increased coverage of over-the-counter medications, and more Medicare beneficiaries reaching the coverage gap (aka the doughnut hole), according to … Read more

NEWS AND COMMENTARY The California legislature is mulling a bill that would slap a moratorium on limited Knox-Keene licenses, which allow physician groups and practice management companies to manage hospital risk, as do HMOs. Accusing physicians of “practicing insurance without a degree,” the Foundation for Consumer and Taxpayer Rights, a watchdog group, is behind the … Read more

The following paragraph is from the American College of Physicians Ethics Manual, 6th Edition: “Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources … Read more

Consolidation of large pharmacy benefit managers and efforts by major pharmaceutical manufacturers to divest themselves of their PBMs suggest that the heady days of growth in the PBM industry could be over. Now, research by SMG Marketing Group may confirm that impression. The numbers of PBMs in business and total covered lives held steady from … Read more

The ink barely dry on its merger termination agreement with Health Systems International, Wellpoint Health Networks has acquired the health insurance business of Massachusetts Mutual Life Insurance Co. Company officials say the deal, valued at $380 million, is “a key element in Wellpoint’s expansion program.” Wellpoint’s acquisition of the Group Life and Health subsidiary adds … Read more

Implementation of stage 2 of the meaningful use standards for physicians seems to be stalled. CMS has paid physicians more than $10 billion for meeting meaningful use standards so far. Physicians have until Feb. 28 to attest that they’ve met the 17 core requirements for stage 2 for their Medicare and/or Medicaid patients. As of … 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. SOURCE: KAISER FAMILY FOUNDATION ANALYSIS … Read more

In time, this may prove to be an interesting lesson in marketing. One year ago, Aetna U.S. Healthcare unveiled a bare-bones, low-cost health insurance product it said was a step toward reducing the number of uninsured Americans. Now, the company acknowledges that its experiment has failed to generate much enthusiasm. Aetna won’t say exactly how … Read more

There’s a chance that health care insurers participating in the ACA exchanges might continue to get the billions of dollars in government subsidies that has made that participation possible. House Speaker Paul Ryan wants the Trump administration to continue making those payments so as not to destabilize the insurance market, the Wall Street Journal reports. Some large … Read more

The ACA somewhat altered the healthcare system at the U.S. by simply lessening the number families and individuals paid in uncompensated care. The action requires every single American to possess medical insurance and assistance to people that aren’t able to afford a strategy. As regulations affects so many Americans, it’s beneficial to know could be … Read more

Building a ‘Terribly Smart’ Doc: A Conversation with David Eddy, MD, PhD Predictive modeling programs are ready for prime time. David Eddy describes Archimedes and what it can do for insurers, patients, and doctors. Messing With Medicare Advantage With Congress engineering big changes, plans are likely to face cuts unless legislators take a new approach … Read more

The CEO of the country’s largest for-profit HMO has jumped with both feet into the national discussion about genetic testing’s place in health care. John W. Rowe, MD, head of Aetna, urges HMOs to make products available that cover genetic testing. “Health plans can play an important role in promoting access to clinically useful genetic … Read more

Insight into federal and state health care legislation & CMS regulation LEGISLATION AND REGULATION Anti-vaxxers Flexing Political, Public Relations Muscle RICHARD MARK KIRKNER They’ve marshalled forces and pushed back on legislative efforts to curb exemptions, although three states have managed to do so. POLITICS AND POLICY As Restrictions on Abortion Increase, Interest in Access Via … Read more

The study detected over 7,020 adults who have type two diabetes using a proven history of coronary illness carrying Jardiance along with this”quality of care” for cardiovascular disease hazard loss and diabetes maintenance. Advisory panel members believed that the solid decrease in premature death passing through the trial was persuasive. But a few participants had … Read more

UnitedHealth Group joins with the YMCA and Walgreens in tackling one of our most vexing chronic conditions UnitedHealth Group joins with the YMCA and Walgreens in tackling one of our most vexing chronic conditions One out of every five health care dollars is spent caring for diabetics, according to the Centers for Disease Control and … Read more

Roche has published a closer glance at the data it expects will propel hemophilia A medication emicizumab into blockbuster status. Emicizumab slice on the bleed rate by 87 percent in patients with inhibitors to factor VIII and aced every one of the secondary end points, which makes lingering concerns about unwanted effects while the principal … Read more

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

The investigation team also found that Slug likely acts as a shield against age-related loss of breast stem cell functioning. May play a part in cancer. The investigation team reported that Slug performs an essential part in a few kinds of breast cancer. Assembling in their previous job, the investigators used breast feeding tissues in … Read more

The National Institute for Health Care Management says more than two fifths of the 18.8 percent increase in outpatient drug spending from 1999 to 2000 was attributable to higher demand. A bit more than a third of the spending increase was linked to newer medications…. HMOs begin declaring this month whether they will stay in … Read more

We do not provide a quote-of-the-week box. Maybe we should, though some tactical problems would have to be addressed. For instance would the quote be lifted from one of the hundreds of news outlets that run stories on health care each day? Or would it be something someone said to us here at this magazine? … Read more

Perinatal quality collaboratives and other responses may help reverse the trend. But payment reform that gets rid of perverse incentives is a prerequisite. In 1960, Singapore’s infant mortality rate was 36 out of every 1,000 babies born alive. That same year the rate in the United States was significantly better: 26 out of every 1,000 … Read more

The search for the educated consumer has been going on for a long time. The ACA expands that effort, hoping that educated young people will rescue reform by flooding the market with healthier beneficiaries who would widen the risk pool while cutting back on expensive uncovered emergency department care. Insurance is complex, though, full of … Read more

Health savings accounts (HSAs) not only do a better job of making workers aware of costs than do health reimbursement arrangements (HRAs), but they also drive more employees into wellness programs, according to a survey by the Employee Benefit Research Institute and Greenwald & Associates. Although the two accounts are similar, the differences between HSAs … Read more

By measuring the inflammatory marker CD154, Pleximmune promises to predict the risk of organ rejection in liver and small-bowel transplant procedures This is a test: Write down the first thing that comes to your mind at the mention the word ‘transplant.’ I’ll bet no one reading this column thought about pediatric liver or pediatric small- … Read more

The phone rang on a Friday evening. A member of a prominent Phoenix-area HMO answered to hear her family practice physician say, “There seems to be an abnormality on your kidney X-ray. It could be cancer metastasized from another site in your body. I will request a referral to a urologist. If no one calls … 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

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

If managed care is to fulfill its goal of promoting wellness rather than simply treating disease, physicians must learn to counsel patients effectively about food and cooking, argues a doctor who is also a cook. Playing a dual role is familiar to Managed Care “Ethics” columnist John La Puma, M.D., a Chicago-based practicing internist who … Read more

For the wellbeing, this primarily means considering questions concerning the continuing outbreak inside their own European outlook and learning the courses which need to be researched to make sure that individuals in Europe are much better prepared future. However additionally, there are other urgent health topics which can be of fantastic importance for the future … Read more

By using Managedcaremag.com (as defined below), you agree to the following Terms of Use, which constitute an agreement (“Agreement”) between Managedcaremag.com and you. IF YOU DO NOT WISH TO BE BOUND OR DISAGREE WITH ANY TERMS AND CONDITIONS BELOW, PLEASE EXIT THE Managedcaremag.com WEBSITE. YOUR SOLE REMEDY FOR ANY DISSATISFACTION WITH IT, OR THESE TERMS … Read more

They’re young, they’re hungry, and they claim to be approaching business problems from a different angle. Will these entrepreneurs succeed? By Steve Heimoff Odyssey Healthcare Inc. Medcath Inc. Trizetto Group Inc. The go-go years of the 1990s have been a great time for health care entrepreneurs. What with the Internet, the booming economy, and startling … Read more

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

The savings to consumers and employers are apparent, but are health plans left holding the bag in mail-order pharmacy? Martin Sipkoff Arecent study sponsored by the Pharmaceutical Care Management Association, the trade organization for pharmacy benefit management companies, concludes that the potential savings to the health care industry from the use of mail service pharmacy … Read more

We invited experts from around the country to weigh in on the strengths and weaknesses of Hospital at Home and what would be required for the concept to succeed in nonintegrated health care settings. Marla Tobin, MD President, Dr. T’s Medical Services, retired senior medical director, Aetna Peter Kongstvedt, MD President, P.R. Kongstvedt Co. Peter … Read more

Insurers need a coverage strategy that focuses on reducing post-surgical complications and avoiding adverse selection Catherine M. Murphy-Barron Despite a national obsession with weight loss, Americans continue to get heavier. There are numerous contributing factors, including increased portion sizes, greater fast food availability, and decreased daily activity. Obesity is often emphasized from a cosmetic perspective, … Read more

Family practice has done better than other primary care specialties in recent years in terms of improvement in base salary, according to a new survey. The top five of 112 surveyed were, in order, gastroenterology, orthopedic surgery, hematology (oncology), otolaryngology, and family practice, according to the Hay Group’s Physician Compensation Survey, which also found that … Read more

In 1995, Dr. Steven Rosenberg published an article in the New England Journal of Medicine (NEJM) that fueled the start of an industry. In a randomized, controlled trial, he showed that an investing in proactive disease management (DM) activities could decrease the cost and improve the quality of life for patients with congestive heart failure. … Read more

Though they’ve generally been good for the public and the companies that spawned them, these organizations often lack direction or fall prey to government raids. The subscriber battles began in the 1980s. Blues and other not-for-profit health plans went up against for-profit plans like Cigna. With no obligation to act as the health insurer of … Read more

Those not-so-long-ago predictions that global capitation would come to define the financing of American medicine haven’t come to pass. In fact, the use of capitation has, more or less, hit a plateau in the past couple of years. Meanwhile, a capitation-rate analysis suggests that physicians who accept capitation contracts are able to negotiate higher rates … Read more

BY NEIL CAESAR, J.D. Deselection of physicians from managed care plans and provider alliances is a significant problem. When a physician member of a medical group is deselected from one or more plans or alliances, he or she can no longer work with patients covered by these contracts unless they pay full fees personally. If … Read more

Who’s Tackling Rampant Overutilization? Health Plans! The nation is in an uproar over rising medical costs, and much of the problem is excess or inappropriate utilization Martin Sipkoff How Insurers Can Bear The Burden of Proof for New Treatments Too often, society prods regulators into adopting new drugs and technologies without adequate scientific analysis Pierantonio … Read more

The most attractive element of the congressional reform plan — at least in the eyes of insurers — is drawing fire in at least 30 states When representatives of the managed care industry took their place at the bargaining table to help hash out a health reform bill last year, there was one clear quid … Read more

By Deborah Epstein Contributing Editor Both managed care and generic medications are intended to help contain health care costs. One would think, therefore, that managed care patients use more generics than other patients. One would be wrong. HMO use of generics is actually about the same as national use, which reached 46 percent of all … Read more

Construction is actually a high-hazard industry that exposes its own labour pool to physical dangers in addition to over all health problems. At the U.S., the yearly overall expenses of deadly and senile injuries within the construction industry are anticipated to be over $10 billion — a figure that doesn’t account fully for the neurological … Read more

Biogen’s 6-mg dose of its own closely observed Alzheimer’s medication aducanumab did not deliver exactly what the Large Biotech and nervous economists were hoping to see, even falling lacking clinical significance about two important measures of efficacy which will have pointed to a transparent path beforehand in an critical study. And the basic safety data … Read more

It has been suggested that comparative effectiveness research (CER) could improve the management and use of treatments, leading to more effective health care and decreased spending. But most research involving CER has neglected the viewpoint of commercial payers. A new study in the American Journal of Managed Care seeks to change that. Anthony Wang, MPH, and others … Read more

A recent court settlement may affect the way the PBM industry makes profits, but could it also lead to higher drug costs? A recent $38.5 million settlement with 28 state attorneys general by CVS Caremark will cost the large PBM more than cash. Coupled with previous settlements in the industry, it will enhance a current … Read more

Predictive Modeling Holds Promise of Earlier Identification, Treatment Proponents see it as the step beyond disease management. Why wait until a patient becomes part of a chronically ill group? Disease Management, Medicaid Mix Like Oil and Water in Florida Other states were looking to Florida to lead the way in Medicaid disease management, but now … Read more

Open a newspaper or magazine or turn on your television these days, and you’ll soon see a report that casts an HMO in a bad light. Here are 10 reasons for managed care’s current run of bad publicity. A headline decries kicking new mothers out of hospitals. A TV talk show bemoans gagging doctors. A … Read more

Although physician income scarcely budged from 2007 to 2008, chief medical officers (CMOs) in managed care organizations saw a marginal increase from 2008 to 2009, according to the most recent Physician Executive Management Center’s report, The 2008–09 Survey of Chief Medical Officers. For 2008, the average salary was $270,262 and the total compensation was $334,171, … Read more

A lot depends on how you frame the question, say researchers at the University of California–San Francisco. “For example, people are more unhappy about losing $100 than they are elated about winning $100,” they say in a study in April’s Health Affairs. Responses by 2,010 adults to four questions about the relationship between quality and prices … Read more

Medicare+Choice may be the first wave in a movement to base payments on risk adjustment. But even advocates admit the technology’s weak. So much of the fairy tale called “progress” involves Technology leading Demand to a clearing in the woods, where appears the magic maguffin. “This is what you want,” Technology says. But is it? … Read more

Increased federal payments to rural Medicare HMOs and the preservation of enrollees’ ability to choose managed Medicare options were among features of the late-July federal budget that drew initial hosannas fromthe HMO industry’s lobbying arm–and criticism from some who don’t consider managed care an unmixed blessing. “Throughout this debate, we have consistently held the position … Read more

As is always the case when I return from working abroad, it takes me longer, metaphorically speaking, to unpack my bags. I was ostensibly in Brazil to teach and consult about innovations in our population health management movement in America. But, as I expected, I was surely the greater beneficiary of teachings from leaders of … Read more

CONTRIBUTING VOICES Finally, the Leavening of Wellness The recent Health and Productivity Conference sponsored by the National Business Group on Health (NBGH) signaled the arrival of what social scientists have long held as vital to the success of wellness: a balance between personal and organizational engagement in health. Read moreabout Finally, the Leavening of Wellness … Read more

Insurers, employers, and telehealth vendors are offering attractive new options for seeing the doctor without leaving home. But some of these programs may be used as an iffy substitute for health insurance, and the savings they can achieve remains uncertain. As Americans increasingly conduct their lives online—shopping, banking, socializing—health care payers, providers, and many employers … Read more

By E. Loren Buhle Jr., Ph.D. Organizations establishing “dot.com” operations on the Internet are Wall Street’s darlings, offering the lure of large profits when the organization goes public. This presumes that online operations will supercharge their markets — and investors’ pocketbooks. While online organizations are truly changing the commercial landscape, online drugstores have many issues … Read more

They’re in the early stages of integrating regional clinical programs that expand treatment options for patients and facilitate effective population health management. Joint venture (JV) health plans created by insurers and health systems are often considered a tactic by the insurer to increase its market share. Anthem’s 2014 partnership with seven Los Angeles health systems … Read more

Authorities have announced its $4.4 billion agreement to buy 1,932 riteaid stores. This may definitely leave Rite Assist with approximately 2,600 stores once the price is completed. The merger arrangement confronted extreme scrutiny from the Start, as it’d have abandoned the usa with two big drugstore chains: Walgreens and CVS. The arrangement had been Re … Read more

Employers and health plans are starting to see the advantage of what has been termed evidence-based benefit design Slowly but surely, the idea that improved quality of care means lower care costs is permeating our health system. “Resistance to that idea is not like it once was,” says Brent James, MD, executive director of the … Read more

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

Managed Care’s Prospects in the Health Reform Era Princeton’s Uwe Reinhardt, PhD, renowned health care economist, sits down with Managing Editor Frank Diamond to discuss the economic effects of the Affordable Care Act, wellness programs, and the state of health care in the United States in general. webadmin’s blog More like this Lawrence Accomplished Much … Read more

Two drugs used to treat asthma and allergies may offer a way to prevent a form of pneumonia that can kill up to 40% of people who contract it, according to researchers at the University of Virginia School of Medicine. Their findings were published in PLoS Pathogens. Influenza pneumonia results when a flu infection spreads to … Read more

Educational effort called”Get before Sepsis” to help protect Americans against the catastrophic results of sepsis. It highlights the significance of early recognition, timely therapy, and additionally preventing ailments which may result in sepsis, that’s your human body’s extreme a reaction to a illness. It’s life threatening, and without timely therapy, can rapidly induce tissue damage, … Read more

All for one, and one for all! Such was the rallying cry for my new client, a physician contracting network. “If we look out for each other,” the network members declared, “we will all enjoy the same opportunities and negotiate the same favorable contracts!” But over the next year, reality set in. One managed care … Read more

As prisoners sign up for the program under health reform, insurers must learn to cope with a problematic population Most people don’t lose sleep worrying about health care services provided to inmates in jails or prisons, but maybe they should. Lack of proper coverage is a major cause of recidivism, experts say, but this year … Read more

Administrative spending by health plans continues to rise for many reasons, including investment in information technology, according to a study by Capgemini, which surveyed health plans that cover over 16 million lives. The consulting company found a huge jump in 2002 over 1999 in IT spending, says Peter Kongstvedt, MD, a vice president of Capgemini. … Read more

BY TIMOTHY KELLEY Twenty years ago, as a weekly-newspaper reporter in the town of Enumclaw, Wash., I spent a day covering flooding that had afflicted several nearby towns. Then I came home to my basement apartment and discovered that the “news” had touched me more intimately than I’d known. I was flooded out. I thought … Read more

In 2017, the fda-approved 4 6 NMEs (visit dining table I at end of article) in comparison to 2-2 NMEs in most 20-16. The 4 6 NME approvals in 20 17 is the 2nd greatest quantity of NME approved by FDA’s CDER, next only to this 5 3 NMEs approved in 1996. The up tick … Read more

New sensor technology could be in clinics next year A breathalyzer designed to detect the early signs of lung cancer is being tested at several British hospitals, with the aim of having the noninvasive technology in clinics in 2017, according to a Reuters report. Cambridge-based Owlstone Medical has developed a microchip sensor technology to measure … Read more

Americans are hungry for medical information, and they’re getting more of it than ever. Some are even retaining consultants who specialize in helping them get the most from doctors and health plans. Jean Lawrence Contributing Editor It’s 1955, standard Norman Rockwell medical-office setting. The white-coated general practitioner pours a few pills into a bottle, hands … Read more

Twilight for Fee for Service? Joseph Burns Although Medicare and most health plans are reworking how they pay for health care, it will take years to eliminate the old way A Conversation With David M. Cutler, PhD: Efficiencies, Jobs, and Staying the Course A Harvard health economist and presidential campaign adviser says cost increases are … 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

Pharmacy & Therapeutics Society works with Institute of Medicine and Leapfrog Group to improve processes. Jack McCain Contributing Editor The original mission of pharmacy and therapeutics committees may have been to select drugs for formularies of health care institutions or health plans, but members of P&T committees also are strongly positioned to expand their central … Read more

Routine therapy is a tool for individuals who take prescribed medication regularly to take care of a health illness, such as arthritis, asthma or higher blood pressure. Additionally, it Lets your family to get the reasonably priced treatment you want and helps your company last with prescription drug coverage. In-step treatment, medications are grouped into … Read more

The clock is counting not just to some Brand New Year, but in addition to some New age in healthcare, the one which is going to be healthier for physicians and patients. This 1 takes hospitals to place their cash and confidential negotiated costs on the web in a easy-to-access arrangement. Soon consumers should have … Read more

Elisabeth Rosenthal, A Storyteller Who Hopes Her Telling Will Make a Difference After penning a book that slams greed, waste, and confusion in health care, Elisabeth Rosenthal, MD, is in a position to push back as editor-in-chief of the increasingly influential Kaiser Health News. Elisabeth Rosenthal, MD, editor-in-chief of the not-for-profit news service Kaiser Health … Read more

For all the talk of change in the state of California’s ability to govern health care delivery, it appears that one group — physicians — is falling through the cracks. California passed a series of health care reform bills last year, including a measure that established a Department of Managed Care to oversee health plans … Read more

Harvard Pilgrim Health Care has striven methodically to become superior in cardiac care. Its numbers tell the story. By Lola Butcher Contributing Editor The statistics for cardiovascular disease and stroke can seem overwhelming: 1 in 3 American adults has at least one type of cardiovascular disease; more than 1.2 million will have a heart attack … Read more

Pennsylvania’s mining of infection info, and the use of insurers’ own statistics in Maine are seen as great examples of measuring quality David J. Carlson, DO, was the chief medical officer of Summit Health System in the mid 1990s when the Pennsylvania Health Care Cost Containment Council first set out to gather outcome data for … Read more

Managing care in the 21st century PETER WEHRWEIN Our inaugural innovation issue! Ah, look at all the lonely people (and resultant health problems thereof) FRANK DIAMOND Deal with people’s isolation and disconnection to head off physical health problems—and possibly health care costs. Shelter from the health care storm LOLA BUTCHER Provide housing for people experiencing … Read more

Despite the continued rapid uptake in specialty and biologic drugs, overall drug spending across commercial, Medicare, and Medicaid managed care plans increased just 2.7 percent last year over 2011.* The effect of specialty drug costs was mitigated by the first decrease in traditional drug spending in more than 20 years, according to Express Scripts. The … Read more

Now there’s discussion of something called “metabolic syndrome,” which seems to include all the problems associated with being obese. An article in the Washington Post notes that some experts are also a bit skeptical, saying that a diagnosis of metabolic syndrome may lead doctors to rush patients into drug treatment without giving dieting and exercise … Read more

Magnetic rectal augmentation is a powerful and safe surgical system of the treatment of gastro esophageal reflux disorder. The apparatus was weighed against twice-daily proton pump inhibitor therapy and laparoscopic fundoplication. Magnetic sphincter enhancement was better than clinical therapy and comparable to operation for the relief of GERD symptoms. Recent research centers on implanting the … Read more

Cost-sharing amounts can vary considerably among Medicare Part D plans for commonly used brand-name drugs without generic equivalents. In general, Part D plans charged more than employer plans did in 2008 for preferred and nonpreferred brand drugs, but somewhat less for generics. Today, more than 26 million people are enrolled in Medicare drug plans, including … Read more

Supreme Court Aside, Lawsuits Will Grow The U.S. Supreme Court says HMOs may not be sued over financial inducements to physicians. The issue is hardly over, though; states are finding other avenues for health plan liability. Cover Story EMR: Putting It All on the Line … Online Electronic medical records have been around for years. … Read more

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

The trend lines and bar charts are marching up. Investors are investing, insurers are extending coverage, health care systems are getting on board. But there are some skunks at the telehealth garden party: research suggesting quality and utilization problems and lingering uncertainty about reimbursement. Telehealth is one of the buzziest areas of American health care, … Read more

No great surprise here: The group Physicians for a National Health Program has come out saying that the federal government should become the single payer for health coverage in the United States. What is surprising to some is that the group put forth its proposal, which is essentially an upgraded and expanded version of Medicare, … Read more

Drugs cost $2.2 billion a year but offer little survival benefit A study published online in Medical Care shows that during a recent 10-year period, the rate of metastatic colorectal cancer patients older than 75 years of age receiving three or more treatments increased from 2% to 53% in the U.S. During this period, the … Read more

ETHICS Risky Business When Public Plays Doctor With Open-Access MRI Michael S. Victoroff, MD So, my friend is headed downtown for his total-body MRI. “How come?” say I. His wife, a radiologist, has arranged a special deal, way less than the $2,500 price her group offers the retail public. Whole-body MRI. Wow. “Why not?” says … 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

Medicare spending has been 15 percentage of overall federal spending 2017, also is estimated to climb to 18 percentage by 2028. Primarily based on the most recent projections from the 2018 Medicare Trustees report, the Medicare Hospital Insurance trust fund is estimated to be emptied in 20-26, 36 months sooner compared to 20 17 projection. … Read more

Bad days in Birmingham: MedPartners lost its trophy dance partner, PhyCor, when the two physician practice management companies nixed their proposed nuptials. In the days that followed, MedPartners stock lost nearly half its value, the PPM was hit with at least three class-action lawsuits and, to cap it, CEO Larry House resigned. Richard M. Scrushy, … Read more

There are things to be said in favor of defined contribution (DC) financing of personal heath care, and writer Tom Reinke rounds them up neatly in his cover story. Chief among these are (1) that getting rid of the defined benefit plan would allow employers to know exactly what their costs would be, since they … Read more

Health care reform sets the stage for employers to bow out of health care, creating an insurance market driven by individual choice, according to Harvard’s Professor Herzlinger It is inevitable that employers will enable employees to cash out the value of their health insurance rather than having employers buy it. The Patient Protection and Affordable … Read more

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

Federal programs face an average 9.3-percent increase in health-benefit premiums next year. The government pins the blame largely on the accelerating cost of prescription drugs. A new report by the Employee Benefit Research Institute named an interesting component of prescription-drug cost hikes. According to EBRI, the number of new prescriptions per office visit increased 15 … Read more

The Congressional Budget Office says the Bipartisan Managed Care Improvement Act would boost employer premiums 4 percent. The Health Insurance Association of America says the CBO “grossly underestimates” liability-induced cost increases…. HMO enrollment will exceed 100 million by 2002, predicts InterStudy Publications. Annual membership growth will average about 5 percent — lower than in previous years … Read more

The failure of the second largest consumer-oriented-and-operated health plan may be a bad omen for the future of other plans. Or maybe not.   If writing laws is akin to making sausage, then the ACA may have been some of the most creative, if not messy, sausage making ever. An example is what negotiators came … Read more

One of the nation’s largest health care companies will analyze claims to discover unintended effects of new drugs on its members. As any pharmaceutical manufacturer is quick to lament, getting a drug approved by the Food and Drug Administration is no simple — or cheap — task. Finding out just how a drug performs once … Read more

The May 17 New England Journal of Medicine 200th Anniversary edition article The Evolving Primary Care Physician highlights key structural, financial, and cultural challenges that confront primary care in the United States. Some of these include training and education that emphasizes ever greater subspecialization, reimbursement that rewards volume versus value, and an increasing reliance on testing versus well-honed history … Read more

“We expect our findings could possibly be the secret to the next therapy. There’s normally very little understanding about the mechanics resulting in Parkinson’s disease. The Issue, It Appears, Is the microscopic Power Houses located in Our brain tissues aren’t able to conform to the consequences of aging in most people who undergo Parkinson’s disease. … Read more

COVER STORY Dangling Dollars Health plans are using financial incentives to encourage members to pick lower-cost providers. Some worry that cutting checks will crowd out quality. Joseph Burns Contributing editor Money has another job. It’s still the root of all evil, but it’s taken on a new role lately as a tool for health plans … Read more

Acorda Therapeutics hits pause on trial enrollment for tozadenant   Five people have died of sepsis in late-phase trials of the Parkinson’s disease medication tozadenant (Acorda Therapeutics, Inc.), leading the company to monitor patients more closely, suspend enrollment in long-term safety studies, and discuss next steps with the FDA and the trials’ independent Data Safety … Read more

WHAT’S OLD IS NEW The per-visit cost of a house call is high, but used judiciously, this practice can lower overall medical costs — not to mention provide better care. During a physician house call, a patient complained of pain and swelling in her leg. Risa Lavizzo-Mourey, M.D., chief of geriatric medicine and director of … Read more

T.V. Parasuraman, Ph.D. Wyeth-Ayerst; formerly of Hastings Healthcare Group, a division of Healthanswers Inc., Pennington, N.J. Patricia A. Deverka, M.D., M.S. Merck-Medco Managed Care, Montvale, N.J. Michael R. Toscani, Pharm.D. Hastings Healthcare Group, a division of Healthanswers Inc., Pennington, N.J. Also available in PDF Using database analysis, this study documents various resources consumed as part … Read more

The U.S. avoided 350,000 hospital-acquired conditions (HACs) for Medicare beneficiaries between 2014 and 2016, representing a decline of 8% that saved $2.9 billion in costs, according to the Agency for Healthcare Research and Quality (AHRQ). In addition, about 8,000 deaths were averted. The HACs in AHRQ’s tally include adverse drug events, catheter-associated urinary tract infections, … Read more

With all the noise made by providers about report cards for physicians and quality grading systems undertaken by payers, it stands to reason that eventually, payers would be put under a microscope, too. Results of a survey conducted by the American Academy of Family Physicians and Family Practice Management magazine indicate that health plans have … Read more

It is exactly what managed care has been promoting for years, but some people worry that the information it creates could be misused Martin Sipkoff Contributing Editor Federally mandated comparative effectiveness research — a $1.1 billion allocation in the American Recovery and Reinvestment Act of 2009, known to most people as the “stimulus bill” — … Read more

There’s a big push for passage this year, but don’t hold your breath. Many feel that such a measure would be too expensive. It’s hard to find any elected officials on Capitol Hill who will come right out and criticize the proposed mental health parity law. Clear majorities of both the House and the Senate … Read more

Fixing their vision therefore that it appears beyond the messenger also concentrates on President Trump’s stated goal to get rid of AIDS from 20 30 isn’t simple for HIV/AIDS urges. Nevertheless they’re not being entirely insulting, either. They’ve some beliefs in, and also working relationships with, national government health officials who’ll oversee execution of this … Read more

Don’t expect quick revision of antitrust laws that forbid independently employed physicians to bargain collectively with managed care plans. Both the Department of Justice and the Federal Trade Commission favor current antitrust policy, which allows only physicians employed by institutions to engage in collective bargaining. However, the issue continues to generate heat in Washington because … Read more

Among all specialists, oncologists may be the most focused on site-of-service issues, especially shifting the care of patients receiving intravenous therapy from hospitals to physician offices. Is this self-interest masquerading as good stewardship of the payer and patient dollar? After all, for a long time, oncologists reaped the benfits of big margins from buy-and-bill prescribing. … 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

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

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

Studies on the disparities in remuneration between primary care and other physician specialties are many, but a new study boils the differences down to the wages-per-hour level. The Center for Healthcare Policy and Research at the University of California–Davis compared wages across broad and narrow categories of physician specialists from data collected in the 2004–2005 … Read more

Many things that were supposed to happen — like electronic medical records — didn’t, this health care futurist reminds us. Tomorrow needs to be shaped. William Rowley, MD, caught the futurist bug in the 1980s from Joel Barker, who popularized the notion of paradigm shifts. “In his tapes, Barker said, ‘I’m a futurist,’” Rowley recalls. … Read more

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

Ingenix was criticized for understating UCR rates, but newer formulas also enrage members who get big balance bills John Carroll Contributing Editor More than three years ago, health plans sat down with New York Attorney General Andrew Cuomo and his staff to hammer out a resolution to a thorny public controversy. Cuomo, now the governor, … Read more

John A. Marcille What goes around comes around.” Those of us not of vindictive temperament hope the adage applies to good things as well as bad. Perhaps that’s the reason physicians seem to warm to the idea of a health care system in which patients can purchase their own insurance with the help of “defined … Read more

The state’s experience is that providers are unwilling or unable to buy into the process The state’s experience is that providers are unwilling or unable to buy into the process Over the coming year, the 800 physicians working at Atrius Health will be in charge of managing the welfare of about 700,000 patients. They already … Read more

An individual safety analysis estimates that over 400,000 American deaths have been related to preventable injury done to patients at hospital settings. Most Americans, such as 55-year-old Louis Salica, that travelled along to a center hospital if he first felt chest pains and has been short of breath, then visit the hospital to find effective … Read more

Follow this link to PDF version COMPENSATION MONITOR In general, salaries within managed care organizations are increasing to keep pace with market demands. Warren Surveys’ Spring 2000 Salary Survey concludes that the rise in salaries indicates that health plans are “keeping compensation at market levels, and understand that in a tight labor market a highly … Read more

The glass-half-empty/-half-full dynamic appeared when the consulting company Deloitte last month released a survey of employer expectations (http://bit.ly/QrAvpg) about the health care system. The finding that 10 percent of employers plan to drop coverage within three years as state insurance exchanges come online was greeted ominously by some. Others thought, What’s the big deal? The … Read more

Health plans blame prudent layman laws for an upsurge in ER visits in the last two years. American Medical News states that Aetna U.S. Healthcare, Cigna, and Humana all report double-digit increases in ER volume, while United Healthcare has charted a 20-percent jump…. PacifiCare will reduce its reliance on Medicare and put more emphasis on … Read more

Follow this link to PDF version As Congress wrestles with Medicare prescription-drug coverage, HMOs are considering how such a mandate would affect Medicare HMOs’ ability to compete for fee-for-service enrollees. A Barents Group study of HCFA data, current as of May, notes that 83 percent of Medicare HMOs’ basic plans offer a prescription benefit — … Read more

SUBSCRIBE TO E-NEWSLETTERS: P&T; and drug management daily news Editor’s letter (bimonthly) Managed Care table of contents (monthly)   2015 2016 2017 2010 2011 2012 2013 2014 2005 2006 2007 2008 2009 2000 2001 2002 2003 2004 1996 1997 1998 1999 1998 January 1998 February 1998 March 1998 April 1998 May 1998 June 1998 July … Read more

Emergency rooms are at Which many patients Have Been introduced into Powerful opioid pain killers, however, suppose that health practitioners offered overthecounter pills as an alternative? The outcomes obstacle frequent ER clinic for healing short term, Acute pain and may prompt changes that can assist in preventing fresh patients by becoming hooked. The research contains … Read more

United HealthCare’s move to make advance authorization “obsolete” generated headlines. Inside the industry, however, the reaction was muted. SIZZLE OR SUBSTANCE? United HealthCare’s move to make advance authorization “obsolete” generated headlines. Inside the industry, however, the reaction was muted. When United HealthCare announced in early November that it is making preauthorization “obsolete” so that physicians … Read more

The trend is unmistakable: Physician executives are leaving their high-pressure, high-paying jobs at health plans, and are starting from scratch in the nascent e-health industry. The lure? A chance to leave their mark on something. Bob Carlson Contributing Editor A number of senior physician executives are leaving managed care for e-health start-ups. Why would these … Read more

Better outcomes and lower costs—in the long run. But payers were not impressed with the oncology medical home.   The rapidly rising cost of cancer care was on every payer’s mind when the buzz started building about a nine-physician oncology practice on the outskirts of Philadelphia. Since 2004, Consultants in Medical Oncology and Hematology had … Read more

They’re in the early stages of integrating regional clinical programs that expand treatment options for patients and facilitate effective population health management. Joint venture (JV) health plans created by insurers and health systems are often considered a tactic by the insurer to increase its market share. Anthem’s 2014 partnership with seven Los Angeles health systems … Read more

A comparison of health care costs in patients with diabetes who do not initially respond to oral therapy suggests that it might be appropriate and clinically beneficial for providers to consider adding another oral agent, rather than up-titrating the current medication, particularly beyond intermediate dose levels Full text available in PDF ABSTRACT Objectives: To compare health … Read more

Online or app-based “chatbots” evaluate symptoms 24/7 and could make health care more accessible and effective. But are they just another toy for the tech‑privileged? P​atients who are worried about symptoms in the middle of the night don’t have to run out to an urgent care facility these days or fuss about landing an appointment to … Read more

Current Zika guidance remains unchanged Scientists at the Centers for Disease Control and Prevention (CDC) have concluded, after a review of existing evidence, that Zika virus is a cause of microcephaly and other severe fetal brain defects. The study findings were published in the New England Journal of Medicine. “This study marks a turning point in … Read more

Decision Support’s New Advocates 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 … Read more

The managed care network shares new ideas about increasing patient satisfaction, reducing hospital admissions, and producing better outcomes overall Few health plans have the benefit of tracking their members for decades, let alone an entire lifespan. US Family Health Plan (USFHP), one of three managed care plan options under TRICARE, the system that provides civilian … Read more

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

Download supplement Respiratory syncytial virus (RSV) bronchiolitis and RSV pneumonia are the leading causes of hospitalization of infants younger than 1 year of age in the United States. Preterm infants, born at 32 to 35 weeks gestational age or less, are particularly at high risk for severe RSV disease. Early recognition of the risk factors … Read more

Health plans are drawing on existing benefits language to make coverage decisions about mifepristone, the newly approved abortion pill. The pill is administered directly by prescribers, so it is not treated as a pharmacy benefit. Among others, PacifiCare, Aetna U.S. Healthcare, Cigna, and United HealthCare cover mifepristone (also known as RU-486) as a standard medical … Read more

These physicians have been on the job for several years, and evidence is mounting that they are one of the HMO industry’s real success stories. Occasionally an important and successful idea about managing care comes along. Stakeholders, including health plans, hospitals, and physician groups test the idea’s viability, investing money and staff time in it … Read more

Managed Medicare Revitalized: Feel-Good Plan of the Decade Insurers are largely happy with what they’ve seen. They’re creating new benefit packages and expect more business in the next one to three years. John Carroll Pharma Tackles Patient Adherence Manufacturers’ programs include Web-based reminders, financial incentives, and full-blown disease management David Adler PBMs Raise the Curtain … Read more

Q&A A Conversation With David B. Nash, MD, MBA: Game Changers for Population Health Bundled payments, big data, and advances in personalized medicine will change the way primary care physicians and others practice David B. Nash, MD, MBA, envisions walking into his primary care practice and accessing an array of tools designed to help him … Read more

Though the common perception is “consumer advocate,” an ombudsman can help doctors and health plans get to the bottom of members’ problems. Charles Downey MANAGED CARE October 1998. ©1998 Stezzi Communications Though the common perception is “consumer advocate,” an ombudsman can help doctors and health plans get to the bottom of members’ problems. Charles Downey When managed … Read more

There’s excellent news for those who have TB illness! It can always be treated and treated with medicine. However, the medication has to be accepted as instructed by your physician or nurse. For those who have TB disease, you need to take a number of diverse drugs. The reason being there are lots of bacteria … Read more

Details may vary according to the characteristics of the providers, but there is a general framework Commercial payers can be a little reluctant to get into a lot of details about their accountable care organization (ACO) contracts, not wanting competitors to know too much. It’s also true that contracts vary according to the size, experience, … Read more

Momentum is building in Washington to address numerous health care issues this year — namely, a prescription drug benefit in Medicare, managed care reform, and finding a way to address the problem of the uninsured. Certainly, there seems to be a mood in both parties to cooperate on several key pieces of legislation. For instance, … Read more

Insurers have not focused much on chronic pain. They should. It presents a humanitarian and business opportunity. Chronic pain is the black hole of medicine, wrenching energy from healing and drawing patients and physicians into a vortex of recrimination and paralyzing self-doubt. Ignorance, prejudice, grievance, fear, failure — troubles swirl around the chronic pain patient. … Read more

Health plans often have to gauge the value of genetic and genomic tests and are forced to make decisions with imperfect information Thomas Reinke Contributing Editor Personalized medicine is caught in gridlock. Just as having too many cars in Manhattan creates rush-hour headaches, having too much information about genetic variants is overwhelming the process of … Read more

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Intelligent and articulate. Those are two adjectives I can use to describe Steve Forbes, a man who thinks he should be president of all the country. I try to get to the National Managed Healthcare Congress every year because many speakers share their knowledge of cutting-edge health care issues. I get to meet people I’ve … Read more

BY BOB CARLSON Why hasn’t pure capitation swept the country? One reason is that some health plans are developing variations on it– especially for paying specialists –that are intended to exploit its power to limit utilization without imposing some of its perverse incentives. One of the most promising new variations is “contact capitation.” In its … Read more

Approved by both the U.S. Food and Drug Administration to take care of frequent urination during the night as a result of nocturnal polyuria. Noctiva Is your first medication approved to treat nocturnal polyuria from the USA, the FDA added. Noctiva, taken approximately thirty minutes before bed, was made to raise absorption of water through … Read more

A think tank’s plan for universal coverage is more in tune with Democrats than with the current Republican administration. Voters can expect to hear a lot about universal health care as the Democratic candidates spar over which of their ideas will do the best job providing an umbrella of medical coverage over the nation. For … Read more

Both largest U.S. drug providers and also a significant Generic drug manufacturer have consented to cover $260 million to repay on the very first federal trial within the businesses’ role in fueling the U.S. opioid outbreak. The agreement will probably buy additional hours for a larger industry payoff in additional opioid instances. McKesson, Cardinal and … Read more

Despite last year’s fiasco at Penn State and growing concern about the effectiveness of such programs, employers are still believers Reports about wellness programs have occupied this space many times. Why shouldn’t they? Employers demand, insurers supply. Jaan Sidorov, MD, a consultant, former health plan medical director, and member of our editorial advisory board, says, … Read more

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

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

By Timothy Kelley Editor See also MANAGED CARE’s cover story for November 1996, Will States Ban Capitation? Oregon voters had occasion this month to consider a moral question with enormous bearing on the delivery of health care in the United States. They were deciding the fate of Salem, Ore., ophthalmologist Gordon Miller’s attempt to ban capitated payment … Read more

Ordinarily, when FDA Requires a growth of this sign for a medication, this usually means that other clinical data also have proven the medication can safely and efficiently treat patient populations aside from those that it had been originally intended. Patient populations are small and therefore are frequently scattered throughout the nation or the entire … Read more

Other states were looking to Florida to lead the way in Medicaid disease management, but now they may want to keep their distance. Three years ago, state lawmakers in Florida fought growing Medicaid costs by backing disease management programs that promise savings and slashing their budgets in anticipation of a payback. This year, they have … Read more

The concerns of Oregon anti-capitation crusader Gordon Miller draw a surprising degree of sympathy from managed care experts. But they say he’s tarring good and bad health plans with the same brush. QUESTIONS RAISED BY THE OREGON VOTE See also MANAGED CARE’s cover story for November 1996, Will States Ban Capitation? Oregon voters had occasion this month … Read more

Bush delivered his remarks about 2000 Based on a White House document published Mondaythe president”considers that inventions in electronic health records and the exchange of health advice may help transform health in America.” The briefing memo says Bush imagines”a radically changed system” by which patients take their healthcare information onto a key chain and could … Read more

Insurance providers together with incentives to allow patients to select physicians categorized as offering healthcare attention on the grounds of why cost-profiling tools are becoming more and more common. But, no rigorous test was undertaken to ascertain if these tools can accurately distinguish higher-cost doctors from psychiatric physicians. We used mobile applications to create clinically … Read more

Employing non-physician and nurse services included in someone navigation program may somewhat reduce health costs and use for cancer patients while still generating a return on investment. By 2013 to 2015, the University of Alabama at Birmingham Health System hired non-licensed team to aid high-cost and insecure cancer patients navigate the health system and their … Read more

F. Randy Vogenberg, RPh, PhD …no matter where he or she is getting care, says F. Randy Vogenberg, RPh, PhD, principal of the Institute for Integrated Healthcare and a member of Managed Care magazine’s Editorial Advisory Board. It’s crucial that different information systems can “talk” to one another. F. Randy Vogenberg RPh PhD’s blog Video

Before a national health information network (NHIN) is built, a realistic estimate of costs is needed. That’s what an expert panel was convened to do, according to a report published in the August 2 issue of the Annals of Internal Medicine. The report is based on expert estimates because primary data are not yet availble. Assuming … Read more

It took him a few more months than expected, but New York Attorney General Andrew Cuomo has introduced a not-for-profit group called Fair Health that is intended to provide insurers with an accurate account of what they owe for out-of-network services. And he is promising that the new operation will have a Web site that … Read more

The technology’s been around, but early participants often were burned. New Internet-based products threaten to turn nonbelievers into yesterday’s news. When Dan Griffin, M.D., finished his medical training two years ago, he began a new course in another type of science: computer technology. For more than two months, working 40 hours a week, he studied … Read more

In Case Southern researchers and development Professionals break in the in- Ternational market, it’s increasingly as advisers, whose conceptual frame- works and also the terminology that they have been predicted to utilize would be by definition dependent on the body. The entire process neatly exemplifies Gramsci’s concept of ethnic hegemony, where the worthiness of this … Read more

n a familiar cartoon, a professor writes long, learned equations on a blackboard. To connect the profundities on either end, he writes in the middle, “Then a miracle occurs.” IPAs, done well, are the miracles that connect the ends of health care.   In a familiar cartoon, a professor writes long, learned equations on a … Read more

Some say much-discussed “alternative” treatments such as acupuncture, naturopathy, homeopathy and traditional chiropractic should be provided by managed care plans. “Bunk!” replies a well-known quack hunter. Should “alternative medicine” be incorporated into managed care? Should managed-care organizations be free to decide this for themselves, or should outsiders dictate what gets covered? “Alternative medicine” has become … Read more

Majority Leader McConnell wants to end repeal debate before July 4 recess Senate Republicans might keep some of the taxes imposed by the Patient Protection and Affordable Care Act (PPACA) for a few more years to pay for their own repeal bill, according to Politico. Many of the upper chamber’s GOP lawmakers want to make their repeal … Read more

AU.S. District Court judge has ordered Blue Cross and Blue Shield of Ohio to relinquish its trademarks–including its name. The health insurer, as one might expect, has filed an appeal. The national Blue Cross and Blue Shield Association sent the Cleveland-based company a letter saying that the plan’s license has expired and that, in any … Read more

With the implementation of Medicare Part D squarely in the rear-view mirror, actuaries at the National Health Statistics Group at the Centers for Medicare & Medicaid Services are turning their attention to the coming demographic shift: Baby-boomers begin to sign up for Medicare. The statisticians expect continued steady growth in national health spending, with some … Read more

The aftermath of some 2012 Supreme Court judgment, says face complex decisions regarding whether to expand Medicaid policy to the entire scope pictured at the Affordable Care Act. With the national government no more able to regenerate growth, nations must base their conclusions on value decisions which comprise each nation’s unique budgetary conditions, the requirements … Read more

Ultragenyx will present voucher to Novartis upon closing of transaction Ultragenyx Pharmaceutical, Inc., has agreed to sell its rare pediatric disease priority review voucher (PRV) to Novartis for $130 million. Ultragenyx was awarded the voucher under an FDA program intended to encourage the development of treatments for rare pediatric diseases. The company received the PRV … Read more

Will insurers provide coverage for a new device that takes much of the guesswork out of screening for this deadly skin cancer? Thomas Morrow, MD Nearly 70,000 Americans will be diagnosed with an invasive melanoma, very difficult to treat, this year. In the past 30 years, the incidence of invasive melanoma has doubled to approximately … Read more

On Saturdaya week after, it’s moving day. Ruth reveals Beneatha The drapes she’s got bought to your brand new house and informs her that the very first thing she’s going to complete within their brand new house is simply take a very long bathroom within their own bathroom. Ruth opinions on the changed mood round … Read more

Michael D. Dalzell Gilead Sciences is likely to be first to market with an oral drug for hepatitis C, after releasing persuasive data from three phase 3 studies of sofosbuvir. With regulatory filings planned this quarter, Gilead could conceivably win Food and Drug Administration approval of the nucleotide previously known as GS-7977 by early next … Read more

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

When cost and disability are taken into account, cancer was third highest, behind heart conditions and trauma (mainly vehicular accidents and violent incidents), according to a Health Affairs article that ranked the 10 costliest conditions to treat in the United States. The National Cancer Institute says cancer care expenditures have been steadily increasing in the … Read more

One of the purposes of health care reform was to create more competition, and the recent spate of acquisitions works against that. Four of the big five commercial health plans have lined up suitors for merger. Aetna and Humana have paired up in a $37 billion cash-and-stock deal, and Anthem wants to buy Cigna for … Read more

MANAGED CARE November 1999. ©1999 MediMedia USA Efforts to overhaul Medicare will wait until next year. House and Senate leaders decided to spend the rest of this year trying to figure ways to pump cash back into Medicare that had been stripped from it by the 1997 Balanced Budget Act. The development means that costly new initiatives … Read more

Specialty hospital construction would be held up for 18 months under a provision in the Medicare reform proposal before Congress. Thanks to intense lobbying by hospital trade groups, lawmakers agreed to a moratorium on construction while Congress studies whether such institutions hurt general hospitals by luring away the most profitable patients…. Health plan liability could … Read more

To paraphrase the Navy, “The tough we do immediately; the impossible we put off forever.” For a while this seemed to be Congress’s and the administration’s stance with respect to salvaging the nearly bankrupt Medicare system. Leaders from both ends of Pennsylvania Avenue met in February and issued a list of top priorities–but the “M” … Read more

Chart Few doubt that universal coverage would have an impact on use of health care services, but just who would use them is subject to debate. A U.S. Agency for Health Care Policy and Research study of the potential effects on behavioral health utilization suggests that expanding coverage would not only induce those with mental … Read more

Insurers know that the new tests can be valuable, but have trouble evaluating them and may not even know exactly which ones they are paying for While much has been written about the promise of new molecular and genetic diagnostic tests, they also bring a tidal wave of complexity, cost, and quality issues for health … Read more

Getting Doctors To Listen to Patients Some physicians are putting new emphasis on careful, active listening to patients. Organizations that don’t encourage this may be ignoring a tool for controlling costs, retaining enrollment and improving medical care. Chuck Appleby Has Productivity Become a Bad Thing? Under capitation, a medical practice’s earnings don’t rise directly with … Read more

A cancer patient who’d previously been denied medical insurance coverage as a result of Her pre existing health state, is only one of several cancer survivors who’ve profited by the variations in healthcare coverage during the execution of this Affordable Care Act, introduced a couple of decades back, now. Gail’s narrative is similar to a … Read more

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

Large employers plan to turn to classic managed care techniques to cut pharmacy costs in 2013, according to a study by the National Business Group on Health. Companies expect benefit costs to rise an average of 7 percent, says NBGH, which represents 342 large employers. “As employers have become more and more challenged by the … Read more

A large number of nations have been falling fast in giving the people a transparent window in to the faculty data they truly are expected to get and document beneath the Every Student Succeeds Act, an advocacy group says, for example a break out of evaluation score dataand achievement, and also subject disparities among vulnerable … Read more

Advances in treating cancer have resulted in a greater number of cancer survivors, but they will also put a strain on the capacity to deliver oncology services in the future. Demand is projected to increase 48 percent by the year 2020. Researchers at Beth Israel Deaconess Medical Center say that the demand is fueled by … Read more

Last August, when his employer was acquired by another company, a 49-year-old man with a history of Type I diabetes, early renal disease, diabetic retinopathy and chronic asthma became a patient turnover statistic. He was forced to change his health insurance from a fee-for-service plan with Blue Cross/Blue Shield to an Aetna preferred-provider organization. As … Read more

A careful look at variations in Medicare spending growth and patterns across the country might hold one key to reining in the rapid growth of health care costs, according to an analysis by Dartmouth University researchers. They looked at Miami, Dallas, and other cities that are experiencing much faster growth in costs than some cities. … 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

Most references to the elephant in the room usually say that no one is talking about it. That’s not the case with how the roles of primary care physicians and specialists will change in an industry that, thanks to health reform, might be dominated by accountable care organizations. Of course, not everyone agrees that ACOs … Read more

In a major coup, Kaiser Permanente has obtained the endorsement of the AFL-CIO as the HMO of choice for its 13 million members. In return, Kaiser formed a partnership with the AFL-CIO that will give 50,000 Kaiser employees who are AFL-CIO members unprecedented say in how to improve patient care and their work environment. “This … Read more

Insurance coverage was never meant to handle new pharmaceutical breakthroughs on the radar — breakthroughs that can cost anywhere from $90,000 to $300,000 a year per patient, says F. Randy Vogenberg, RPh, PhD, principal of the Institute for Integrated Healthcare and a member of Managed Care magazine’s Editorial Advisory Board. There will be pressure on … Read more

Increasingly, treatments are being developed that combine the use of devices and medication. Thomas Morrow, MD More often than not, advances in medical technology can make the job of the medical and pharmacy director highly complicated. To manage their patients successfully, clinicians have to develop comprehensive processes that integrate the medical and pharmacy benefit, choosing … Read more

The most suitable Way of minimal residual disease Discovery in chronic lymphocytic leukemia continues to be contentious. Of 9-2 samples, 14 examined in parallel with MRD stream and from ASO IgH RQ-PCR had been negative by our flow cytometric assay however positive by PCR, hence demonstrating superior significance of RQ-PCR using ASO primers. MRD detection … Read more

Renewed Emphasis on Top-Tier Physicians Employers want networks limited to only the highest performing physicians, and new tools can help clinical executives sort them out Frank Diamond Don’t Pay Too Much for Generic Fills Pass-through pricing is a good way for a payer to realize the benefit of increased prescribing of generic drugs Linda Cahn … Read more

The cost of treating stroke victims will soar in the next two decades, according to a study by the American Heart Association and the American Stroke Association that was published in the journal Stroke. Real total direct annual stroke-related medical costs are expected to increase from $72 billion to $183 billion (2010 dollars) between 2012 … Read more

Commission has declared Perjeta® in conjunction with Herceptin® and chemotherapy to get post-surgery treatment of adult patients using HER2 positive premature breast cancer in high risk of recurrence. High threat of recurrence is characterized as respiratory node-positive or hormone receptor-negative illness. The Perjeta-based regimen ought to be administered for a total of twelve months as … Read more

This article evaluates recent trends and challenges in health system management of exceedingly rare genetic diseases, from the perspective of the manufacturer, managed care organization, physician, and actuary. Mark Zitter, MBA Chief Executive Officer, The Zitter Group, Millburn, N.J. Continuing Education Full text available in PDF ABSTRACT: Managed care organizations generally pay for expensive drugs that … Read more

There is near-universal consensus that “value-based care” is a good and worthy objective. In any instance when unanimity embraces an idea, a thoughtful person might ask whether there’s true agreement or perhaps just a cone of vagueness that accommodates a variety of opinions and lets eyes of the beholders see what they want to see. … Read more

Manufacturers’ programs include Web-based reminders, financial incentives, and full-blown disease management Nonadherence — failing to fill a prescription, taking it incorrectly, or discontinuing taking it — is a huge health and financial burden in the United States. Sixty percent of statin patients discontinue treatment prematurely over the course of a year. Forrester Research, a technology … Read more

Rwanda is called the land of a thousand hills, and also our car appears to discuss each of these since we drive out of the little town of Muhanga into the smaller town of Kinazi. The 50-kilometer I visit western Rwanda will need us well within one hour. The drone has been controlled by zip-line, … 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

Aetna AET.N along with Humana HUM.N Would think about all available choices to his or her projected $ 3-4 million merger, the 2 U.S. health insurance said on Tuesdaya day after a court ruled against the bargain as a result of worries it might lower rivalry. A dealer points upward at a screen onto the … Read more