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

Theranos CEO Banned From Operating Lab for Two Years CMS drops hammer on beleaguered company   Embattled blood-testing company Theranos has received notice from the Centers for Medicare and Medicaid Services (CMS) regarding the imposition of sanctions arising from a 2015 evaluation of its laboratory in Newark, California. Among several rulings, the CMS has banned … Read more

HSAs, FSAs, HRAs — it’s all alphabet soup to many employers. HMOs need to be able to accommodate all sorts of new payment schemes. Executives and human resources personnel at EnPro Industries, a manufacturing company based in Charlotte, N.C., that makes engines, air compressors, and other products for a number of industries, is sorting through … Read more

These systems can improve quality, but in their present state of development, they can annoy physicians and are underutilized 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 Mrs. Jones … Read more

The anti-managed care drive continues at the state level. State legislatures are zeroing in on the definition of “emergency services” by managed care plans, and their reimbursement policies for care delivered in emergency rooms. Concern is growing over reports of patients who have sought emergency room services and discovered after the fact that reimbursement for … Read more

Telephone prescribing, it seems, has been on the rise. In one unnamed network of 19 primary care practices, the number of prescriptions for antibiotics given over the telephone jumped from 2.2 per 100 patient-years in 2006 to 4.2 in 2010, according to a study in the journal Pharmacoepidemiology and Drug Safety. Of the total 63,418 … Read more

Managed Medicare and Medicaid especially struggle to develop improved discharge and follow-up systems Lola Butcher Contributing Editor 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 … Read more

A Stat News analysis found that tens of thousands of patients carrying the RA medication expired from pulmonary and cardiovascular complications — problems the medication wasn’t generally related to. In accordance with the evaluation, Actemra didn’t take warning labels regarding the potential unwanted effects, including most rival RA drugs. Stat said it researched a lot … Read more

Bereft of his own connections, President Trump recruited from conservative think tanks to fill health care positions in his administration. Many of them have Koch brother connections, and their agendas often run counter to Trump campaign rhetoric—and his impulses. Illustration by DonkeyHotey/Flickr Before he joined the Supreme Court in the ’70s, Lewis Powell was a … Read more

HEALTH PLAN 2009 As the Managed Care editorial team gathered the names of policy experts to approach for our five-year look forward, we were struck by how quickly we could fill a page with candidates who would have a valuable perspective. After weeks of whittling and editing, we are proud to present these essays from … Read more

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

2019: Jan Feb Mar Apr May Jun Jul Aug 2018: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2017: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2016: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Malpractice premiums constitute small component of expenses Few issues galvanize the medical community like the cost of malpractice insurance, but a recent survey shows that the increases are less severe than many physician advocacy groups suggest. A study published in Health Affairs reports that surveys of self-employed physicians from 1970 to 2000 indicate that premiums … Read more

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

Gail R. Wilensky tried to warn us. Wilensky, who ran Medicare for Bush père in the early 1990s and is now the John M. Olin Senior Fellow at Project HOPE’s Center for Health Affairs, was the subject of our Question & Answer department back in July. In that interview, she doubted that Congress would pass … Read more

MANAGED CARE August 1998. ©1998 Stezzi Communications The debate among state legislators and managed care regulators about coverage of Viagra, Pfizer’s popular anti-impotence medication, continued on two fronts last month. A number of states rejected a federal order that Medicaid programs cover the drug. And legislators in California called for an investigation of commercial health insurers that … Read more

Look closely at the trend in salary expectations for physicians in various specialties over the past three years, as shown in an annual survey, and you’ll see the fingerprints of managed care. Pay expected by family physicians and internists, often sought after by HMOs to play a “gatekeeper” role, has tended to move upward, unlike … Read more

While development of depression management programs has lagged behind other chronic conditions, emphasis is now being placed on early diagnosis and treatment coordinated by primary care physicians. In the race to design disease management programs, drug manufacturers, pharmacy benefit managers, managed care companies and other health systems have been expending a lot of energy on … Read more

NCQA decided not to hold managed care companies that do not carve out behavioral health benefits to the same accreditation standards that managed behavioral health organizations face — at least, for now. NCQA’s managed behavioral health organization accreditation program began last year. Next year, NCQA would have extended those standards to plans that administer mental … Read more

With CMS Demanding More Accountability in the MSSP, Will It Be ‘ACOs Overboard’? Three quarters of the original ACOs that remain in the MSSP are still in Track 1. The Trump administration is tired of waiting for them to take on two-sided risk. That splash you hear may be dozens of ACOs jumping off the … Read more

Medicare Part D and the Department of Veterans Affairs (VA) are two major government payers of health benefits that use different approaches to managing prescription drug benefits, and a study that looked at managing brand-name prescription drugs shows a vast difference in efficiency. Walid F. Gellad, MD, MPH, and colleagues reviewed brand-name diabetes medication use … Read more

Predictive modeling programs are ready for prime time. David Eddy describes Archimedes and what it can do for insurers, patients, and doctors. David Eddy, MD, PhD, has been an advocate of evidence-based decision making in medicine for more than 25 years. A surgeon by training, he went on to study mathematics with the goal of … Read more

Merck & Co stated the U.S. Food and Drug Administration fell a software to include advice regarding labels of its own diabetes medication – Januvia and also Janumet – which the treatments don’t enhance the possibility of big cardiovascular issues. Merck is estimating the agency’s answer for the use, the organization said on Friday. The … Read more

Color chart 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.

COVER STORY Aetna Joins With Providers In Private-Label Health Plans A partnership with a respected hospital system or large physician practice could increase a health plan’s market share One of the troubling aspects of accountable care organizations(ACOs) in the eyes of providers is the long-term business model. Hospital administrators and physicians are accustomed to revenue … Read more

Maybe next year? Despite gloomy predictions of a return to double-digit premium increases and such highly publicized incidents as the CalPERS-Kaiser snit, health plan premiums have risen only 3.3 percent in the past 12 months, according to findings by KPMG Peat Marwick’s compensation and benefits practice. The consulting firm says two strong undercurrents have held … Read more

LEGISLATION & REGULATION Fearful After Enactment of ACA, Brokers Find New Opportunities The Affordable Care Act had brokers thinking they would lose business. Now they are working with private exchanges and adapting in other ways. Longtime Chicago health insurance broker Tim Elenz watched his market undergo a sea change with the passage of the Affordable … 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? 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 frightful influenza pandemic of … Read more

The number of Americans age 45–64 suffering from at least two chronic conditions grew from 16 to 21 percent between 2000 and 2010, according to a study by the Centers for Disease Control & Prevention. For people age 65+, the number with at least two chronic conditions increased from 37 to 45 percent. It gets … Read more

A fatal disease with many victims, IPF has been shown to progress more slowly when treated by pirfenidone. The FDA itself has not yet ruled on it. Idiopathic pulmonary fibrosis (IPF), the most common form of interstitial lung disease, is a crippling and ultimately fatal disease diagnosed in about 30,000 Americans each year — making … Read more

Geisinger Health Plan is often mentioned by experts as one insurer that does transitions of care well, thanks to the 70 case managers it employs to oversee people admitted to the hospital. The program, Health Navigator, has cut readmissions by 20 percent, overseeing nearly 70,000 lives, about two thirds of them Medicare beneficiaries and half, … Read more

Epidiolex treats pediatric epilepsy GW Pharmaceuticals, a marijuana biopharma company based in the United Kingdom, is on track to submit its lead candidate Epidiolex to the FDA for approval during the first half of 2017 for the treatment of Dravet syndrome and Lennox–Gastaut syndrome (LGS), according to an article posted on the FierceBiotech website. Both indications are rare … Read more

Phase 3 clinical trial of investigational agent began in October 2016 The FDA has granted a fast-track designation to Eisai, Inc., for the development of E2609, a beta-secretase cleaving enzyme (BACE) inhibitor currently being evaluated in phase 3 clinical trials for early Alzheimer’s disease (AD). E2609 was discovered by Eisai and is being jointly developed … Read more

Cross-Border Traffic Highlights Differences in U.S., Canadian Systems Policy experts see the Canadian system as an example but differ on the significance. Meanwhile, some U.S. providers are cashing in. Interesting things happen to two adjacent countries with dissimilar health care funding and delivery mechanisms: Differences in access and cost of care create individual and institutional … Read more

Provide housing for people experiencing housing instability, some of whom are health care’s super utilizers. Their health will improve, and their utilization will go down. The family is poor, unable to afford housing anywhere except the Navajo Nation, more than 300 miles away from the Phoenix Children’s Hospital. Family members—including a very sick child—are insured … Read more

In Phases I and II of the market evolution currently under way across the country, increased managed care penetration and the beginnings of coordinated competition prod physicians and other health care providers to form alliances designed to take on financial risk, implement and enforce rudimentary quality assurance and utilization review duties and find ways to … Read more

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 Maryland and the United States. The physician … Read more

Abstract Purpose: Current asthma guidelines combine treatment, follow-up, and reevaluation to manage asthma control, reduce impairment, and decrease risk of morbidity in patients. Clinical use of biomarkers, such as fractional exhaled nitric oxide (FeNO), along with standard management can provide clinicians with improved ability to recognize airway inflammation, optimize drug therapy, and potentially increase asthma control. … Read more

John Marcille We heard a lot about primary care in the early days of managed care. Gatekeepers were supposed to steer patients to specialists only when necessary, and even limit unnecessary treatment. They still do that, but to a much lesser extent. Remember, we also heard a lot about the Patients’ Bill of Rights. The … Read more

The introduction of new pharmaceutical products drove a 9-percent increase in per-capita prescribing last year. Physicians wrote an average of 2,060 prescriptions each, according to a survey by Scott-Levin…. A study by the Center for Studying Health System Change says more than two thirds of people who obtain new coverage do so not by choice, … Read more

Washington Initiatives Managed care has wrung about all of the excess from the health care system that it can — and as a result, health care spending is about to jump dramatically, says the Health Care Financing Administration. In a study released in the September/October issue of the journal Health Affairs, HCFA actuaries credit the … Read more

With Weight Management, One Thing Leads to Another Submitted by Paul Terry on Mon, 2012-10-15 21:47 John Muir, the famous naturalist, wrote: “When one tugs at a single thing in nature, he finds it attached to the rest of the world.”  It’s a concept that’s long overdue but now fully ensconced in the field of … Read more

Given their instant approval to get remedy duo in 2 weeks, voting 1 2 to two to ago Sanofi’s marketing application for a combo of its own franchise blockbuster Lantus and the glp 1 medication lixisenatide–currently dubbed iGlarLixi. There is one abstention. Much like the unanimous vote Tuesday favoring Novo Nordisk’s IDegLira, plus a mixture … Read more

Also available in PDF Abstract: Hypertension remains uncontrolled in approximately 50% of patients with hypertension, which increases the risk of cardiovascular morbidity and mortality in these individuals. A key factor contributing to poor blood pressure (BP) control is nonadherence to prescribed antihypertensive medications. Improving patient adherence to antihypertensive therapy is the key to improving BP goal … Read more

Just Say “No” A visit to my dental hygienist this week began with a conversation about diagnostic tests. Before the dental x-rays, I asked Dottie if I needed x-rays, and she replied that it had been 18 months, and, based on my age and past dental history, every year to two years was a reasonable … Read more

John A. Marcille The things that cost us the most often come without price tags, just as the things we value the most usually can’t be bought. Senior Editor Frank Diamond’s cover story concerns hidden costs resulting from the oft-strained relationships between HMOs and physicians. A substantial portion of this figure — whatever it is — is … Read more

The double-digit annual average percentage increases in health insurance premiums that prevailed in the late 1980s have given way to a modest 0.5 percent increase for 1996, according to a national survey of employers by the employee benefits consulting firm KPMG Peat Marwick, which attributes the welcome relief to the embrace of managed care plans … Read more

Every practice has someone in charge. It may be an executive-level administrator, a seasoned office manager, or a “lead” employee who works without the title. Sometimes it’s the doctor. There’s a lot to the job, and not everyone does it optimally. Look for these signs and symptoms that indicate your office manager needs improvement. In … Read more

Although there are no perfect solutions to the problem of dangerous drug interactions, there are steps HMOs and health care professionals can take to minimize risk. The American Pharmaceutical Association is observing National Pharmacy Week, Oct. 18–24, by encouraging better consumer communication with physicians and pharmacists to reduce that risk. And APhA is using the … Read more

A group of investigators at Florida State University, Johns Hopkins University, and the National Institutes of Health has identified 2 types of substances which may potentially be employed to take care of Zika virus illness (ZVI)–a person which prevents the herpes virus from replicating and one other which prevents the herpes virus from murdering neuroprogenitor … Read more

Public fascination with alternative medicine gives health plans a can’t-miss business opportunity. Science may determine whether plans’ interest lasts Anyone who thinks he is having a flashback, raise your hand. The popularity of alternative medicine has a 1960s feel to it: natural products, an interest in Asian practices, a willingness to defy convention and accept … Read more

January ePub Biosimilars January/February Medicare Advantage and the Future of Medicare Also: Women’s health March Disintermediation: The War Against the Middlemen in Health Care Real-world evidence April Emergency Medicine HIV/AIDS May Opaqueness: What’s Hidden in American Health Care Oncology June General Interest Evidence-based medicine July/August Second Annual Innovation Issue Diabetes August ePub Special Topic September … Read more

The brand liver cancer detection evaluation comes with a reduced false Favorable and false positive pace. In excess of 700,000 sufferers have been at greater risk for liver cancer at the U.S., and there’s really just a 15-fold growth in survival speeds whenever the cancer has been discovered at first phases versus late night periods. … Read more

Many problems attributed to outcomes measurement result from poor planning before a program is initiated. A DM expert lays down some ‘must-do’ rules for success in this excerpt from Disease Management and Wellness in the Post-Reform Era, published by Atlantic Information Services Inc. Al Lewis Perhaps no issue in disease management (DM) is more controversial … Read more

John A. Marcille We’ve come down foursquare for the Anglo-English alliance this month, as two of our stories show that we can still learn a thing or two from our older British cousins. Our cover story on movement toward a national EMR system compares what’s going on here to how a similar effort is being undertaken in … Read more

In a new study of how consumer-directed plans are doing, one finding is that lower premiums was not a major factor in whether workers selected such a plan. MargaretAnn Cross As insurers enter 2004 refining, designing, and, contemplating consumer-directed health plans (CDHPs), a new study from the National Business Group on Health’s Institute on Health … Read more

Name Last modified Size Description Parent Directory 11-Jan-2005 13:10 – ../../../archives/0005/0005.weiner.pdf 01-May-2000 12:00 124k 0005.weiner.html 09-Apr-2003 23:32 45k ../../../archives/0005/0005.outlook.gif 01-May-2000 12:00 44k ../../../archives/0005/0005.outlook.pdf 01-May-2000 12:00 40k ../../../archives/0005/0005.compmon.pdf 01-May-2000 12:00 36k ../../../archives/0005/0005.compmon.gif 01-May-2000 12:00 34k 0005.pity.html 09-Jun-2003 11:44 26k 0005.broker.html 09-Jun-2003 11:44 17k 0005.qna_eisenberg.html 09-Jun-2003 15:00 17k ../../../archives/0005/0005.cover.jpg 01-May-2000 12:00 12k 0005.conf.html 09-Jun-2003 11:44 8k 0005.states.html … 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? 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 get three … Read more

John A. Marcille Every once in a while, we here at Managed Care methodically — sometimes agonizingly — piece together a theme issue in which two or three articles focus on a single topic or on related topics. This usually takes planning, coordination, and insight. Or, we stumble into it, which seems to be what … Read more

Recent advances in pain relief revolve around longer-lasting implantable devices. Can you afford not to have a pain management strategy? Thomas Morrow, MD MANAGED CARE May 2005. ©MediMedia USA Recent advances in pain relief revolve around longer-lasting implantable devices. Can you afford not to have a pain management strategy? Thomas Morrow, MD Recent headlines concerning COX-2 medication … Read more

Revolution” (FIR) can be a era of high level technology predicated on information and communicating. FIR includes a more potent influence on the market than previously. Nevertheless, the prospects of the labour environment are unclear. The objective with this study would be to expect and prepare yourself for occupational health and safety (OHS) problems. In … Read more

The president of the Union of American Physicians and Dentists pulls no punches in describing the conflict between physicians and insurers. A Conversation with Robert L. Weinmann, M.D. After launching the Union of American Physicians and Dentists in 1972, founder Sanford Marcus, M.D., met with George Meany, president of the AFL-CIO, seeking an affiliation. Expecting … Read more

Martin Sipkoff Contributing Editor Now that tiered formularies rule the land, what many suspected is being demonstrated: Compliance is suffering and so, too, are patients. MANAGED CARE August 2004. ©MediMedia USA Now that tiered formularies rule the land, what many suspected is being demonstrated: Compliance is suffering and so, too, are patients. Martin Sipkoff Contributing Editor When … Read more

WASHINGTON INITIATIVES The Year 2000 bug is quite the menace. HCFA doesn’t really have a handle on the problem, according to Illinois Republican Rep. John Porter, chairman of the House panel that oversees the agency’s operations. Porter said HCFA is in deep trouble because only 40 percent of its almost 500 “mission-critical” computer systems currently … Read more

The Department of Health and Human Services extended the comment period for proposed privacy regulations to Feb. 17, giving groups time to determine whether unintended consequences would prevent coordinated care…. Only 5.9 percent of HMO members rate trust in their health plans “very high” in a National Research Corp. survey. If that seems low, it’s … Read more

The importance of a gatekeeper in keeping costs down has been challenged again — this time in a study that compares physician utilization for HMOs and point-of-service plans. The study, sponsored by the U.S. Agency for Healthcare Research and Quality, found no evidence that HMOs that use primary care physicians as gatekeepers keep specialty costs … Read more

Requiring hospitalization in adults with recognized cardiovascular illness. “Now’s “Praluent has recently helped many individuals lower their ldlc levels, also this brand new sign stipulates a chance to help ideal patients by lessening the probability of acute, lifethreatening cardiovascular disease, including heart attacks and stroke” Top Adults who undergo a heart attack or stroke possess … Read more

Medication-assisted treatment could be using medications together with counseling and behavioral treatments, that works well in the treatment of opioid use disorders and helps many people to sustain healing. More should be done in order to alleviate treatment plans and also the development of treatments to handle OUD because of chronic illness with long-term consequences. … Read more

Joseph Newhouse, PhD HEALTH PLAN 2009 Joseph Newhouse, PhD, is the John D. MacArthur Professor of Health Policy and Management at Harvard University and head of its interfaculty initiative in health policy. He also sits on Aetna’s board of directors. Envisioning what health care will look like in five or six years can be difficult … Read more

By Howard Salmon and Rick Carter More than ever before, quality matters in competing for managed care contracts. Employers and the insurers who pay most of the medical bills are feeling the heat from employees and subscribers who demand that their health plans contract only with the “best” doctors. Of course, any self-respecting physician would … Read more

Too many pills means lower adherence to antiretrovirals in HIV patients Evidence-based interventions to improve adherence have become a focus of formulary decision makers. Regimen simplification works — up to a point. Once-daily dosing only slightly improves adherence compared with twice-daily dosing, according to study in Clinical Infectious Diseases. Continue reading… Contributing Voices Drug Cost-Sharing Amounts … Read more

Medco’s ‘gaps in care’ approach saves $900 million by targeting 15 chronic conditions   Its costs exceed $177 billion annually. It results in 125,000 deaths, nationwide. Nonadherence to medication is so prevalent that about half of the 3.2 billion prescriptions issued in the United States are not taken as directed. To encourage compliance, Medco Health … Read more

As the design approaches its seventh year in the marketplace, some wonder if it will ever be more than a niche product Despite all the interest in consumer-directed health plan design by employers, health plans, and government officials, this “revolutionary” design is sputtering. Towers Perrin, the giant consulting company, reports that employees in account-based health … Read more

You’ve read the stories and heard all the news: Insurers and employers are passing more and more health care costs along to members. But how much have pharmacy copayments risen? NDCHealth reports that in the top 10 therapeutic categories, the greatest increases were in antiseizure agents, inhaled steroids, and antiarthritics. At the bottom were antihypertensives … Read more

How Managed Care Affects the Malpractice Liability Problem Managed care has the potential not just to achieve savings, but to improve health care outcomes dramatically. But does it create extra malpractice complications along the way? The experts disagree. An Emergency Physician Complains: ‘Your Patients Are Costing Me Money!’ In getting paid by managed care plans, … Read more

Even if employees were motivated to get more involved in health care coverage decisions, and even if they had the know-how to weigh all the variables before making those decisions — two big ifs — they would not have access to the sort of informa-tion that they’d need to pull this off, says a report … Read more

Just because you hear a whistle from two miles down the track doesn’t mean it’s time to hoist your heavy suitcase. American health care has been waiting a while for “value-based payment” to pull into the station. But don’t look for it to fully arrive in 2016. Propelled by the ACA’s ACOs and new Medicare … Read more

By Deborah Epstein Contributing Editor With its promise of cost control largely kept, managed care is widely proclaimed to have entered a new era in which health plans compete on the basis of quality. Central to the task of achieving high quality, of course, is getting physicians to use the processes of care that have … Read more

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

John Marcille Change isn’t always progress, but in this case, it surely is. The move to ICD-10’s vastly expanded set of disease and procedure codes is necessary because of the many changes in medicine and surgery that have taken place over the decades since the last true overhaul of the ICD code set over 60 … Read more

The FDA granted priority review into copanlisib for Its Procedure of The regulatory entry for copanlisib is predicated on results in the open-label, single-arm phase two CHRONOS-1 analysis, made to assess the efficacy and safety of copanlisib monotherapy from 141 patients with relapsed or refractory indolent non-Hodgkin lymphoma — for example follicular lymphoma — that … Read more

Based on outcomes of this IMPROVE-IT analysis of sufferers Five members of this committee voted that efficiency and safety data in IMPROVE-IT provided enough evidence to accept the brand newest signs, along with 10 members insisted the information didn’t offer enough evidence. Back in IMPROVE-IT, in comparison to simvastatin alone, simvastatin And ezetimibe was correlated … Read more

HMOs place great stock in disease prevention, but some highly recommended services go uncovered. Plans and purchasers often don’t agree on priorities. Michael D. Dalzell Managing Editor Some 130 years ago, the Union Pacific Railroad stood out when it helped to complete the first transcontinental rail line — no small feat, accomplished through the sweat, … Read more

What New Year’s Day did you create this season? In the event that you resolved to shed weight, exercise reduce stress, you are one of many. Think about the household ? Can you get any resolutions on them? You see your dentist every six weeks and change the oil in your Auto Every 3,000 miles, … Read more

The importance of a gatekeeper in keeping costs down has been challenged again — this time in a study that compares physician utilization for HMOs and point-of-service plans. The study, sponsored by the U.S. Agency for Healthcare Research and Quality, found no evidence that HMOs that use primary care physicians as gatekeepers keep specialty costs … Read more

The man heading an ambitious effort to transform how health care’s delivered keeps a low profile. Atul Gawande, MD, the nationally known health care expert who is leading an effort by Amazon, JPMorgan Chase, and Berkshire Hathaway to do the little job of transforming the entire health care system has pulled out of giving the … Read more

“We don’t know for certain whether there’s cost shifting going on, but it’s unlikely that people are turning around their health status so quickly” and savings have to come from somewhere, says Jill Horwitz, JD, PhD. Workplace wellness programs are increasingly popular with employers and vendors. Jill Horwitz, JD, PhD, has good reason to believe … Read more

Four-Tier Approach Injects Consumerism Into Drug Benefit In tying copayments closely to the actual cost of medications, Humana takes a step toward promoting awareness of resource use. Consumers Dare You to Just Say ‘No’ The backlash has helped push a Patients’ Bill of Rights forward, challenging the very nature of cost containment. Ironically, enrollees may … Read more

Health plans and physicians have every right to hold down the cost of pharmaceuticals, as long as patients aren’t harmed. But not everyone agrees on what actions are acceptable. Many managed care organizations believe that cost containment can be achieved in part or whole by restricting the drug choice of both health care practitioners and … Read more

Shoulder pain, carpal tunnel syndrome, and other repetitive stress injuries can be avoided with this advance As the readers of this column ponder their day-to-day challenges relating to the rapid development of medical technology, it is fascinating to wonder what people from the past, let’s say the 16th century, would have said about these new … Read more

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

Evaluating the Nondrug Costs of Formulary Coverage Restrictions Substantial nondrug costs result from switching prescribed medications in response to changes in insurance coverage, and many nonreimbursed costs shift to providers and patients. Consumer-Directed Health Plans: Enrollee Views, Early Employer Experience As CDHPs increasingly penetrate the commercial market , their greatest contribution might lie in funding … Read more

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

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

The AMA is evaluating how and whether to proceed with its physician accreditation program, which has been unable to gain attention from health plans and hospitals. Credentials verification and site reviews will be completed for physicians who have applied for AMAP certification, but no new applications are being accepted for now. The goal was for … Read more

The Weight of the Nation: How Many Rounds Ahead for This Public Policy Fight? 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 … Read more

The stimulus bill’s $27 billion for health information technology will go to providers, but health plans will experience other financial and operational benefits. When Congress passed the stimulus last year, it included in the law a multibillion-dollar subsidy that legislators hoped would promote a high-tech revolution in health care. The law stipulated what kind of … Read more

Practice-based research has a long and honorable history. Well before there was an NIH or an IRB, there were practicing community physicians making observations. For example, in our own practice, more patients than ever are overweight or obese. Neither diet pills nor conventional weight loss programs seem to help for long. Rebound weight gain is … Read more

Medical group practices that are owned by hospitals or integrated delivery systems (IDS), or are just affiliated with them, are no more immune to cost increases and pressure on payment rates than are their physician-owned practice counterparts. New data indicate that total operating costs per full-time equivalent (FTE) physician in IDS medical group practices increased … Read more

The renewed hope that shared decision making might finally fulfill its promise and lower costs (see our April cover story http://tinyurl.com/Burns-shared) just hit some static. Patients who participate in their medical decisions spend more time in the hospital (0.26 of a day) and raise the cost of their stay by an average of $865, according to … Read more

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

This new class of antibiotic — the macrocycles — has a greater sustained response against re-infection than vancomycin Except for topical medications such as creams, lotions, and eye drops, in general, medications work in the body by being absorbed into the bloodstream and traveling to the needed receptor to perform a task. But the Food … Read more

Ombudsmen: Navigating The Managed Care Maze Though the common perception is “consumer advocate,” an ombudsman can help doctors and health plans get to the bottom of members’ problems. Charles Downey Buy Health Insurance Like Car Insurance? A simple idea with huge implications: Let employees purchase their own health insurance with the help of “defined contributions” … Read more

EMPLOYER UPDATE Having employer-sponsored benefits does not guarantee good service. Differences in race, education, and income are also factors. MargaretAnn Cross As employees at Kellogg, in Memphis, submitted to fingerstick cholesterol screenings and picked up health pamphlets at the cereal company’s annual health fair last month, many also for the first time talked with on-site … Read more

Past examinations have shown that abundance weight gain and raised glucose during pregnancy increment a lady’s danger of conveying an enormous child who is bound to turn into a fat youngster; nonetheless, as of not long ago, there wasn’t a lot of proof that these danger factors additionally influenced typical weight children. “At the point … Read more

Data include personal health records and insurance providers   August 4, 2016 A Ukrainian hacker has stolen more than 100,000 internal documents from Central Ohio Urology Group, a small medical practice in Gahanna, Ohio. The hacked data include personal health records from 2013–2014 containing patients’ names, addresses, phone numbers, diagnoses, and insurance providers. The hacker … Read more

Physician rallies to raise awareness of the skyrocketing costs of malpractice premium insurance have blamed many parties, including government, the insurance industry, and especially lawyers. Long the butt of jokes, malpractice and trial lawyers find themselves coming under fire from one of the strongest lobbying groups in the country — physicians. A review of the … Read more

Company failed to correct 43 of 45 lab deficiencies In a letter dated March 18, officials at the Centers for Medicare and Medicaid Services (CMS) proposed banning Theranos Inc. founder Elizabeth Holmes and the company’s president, Sunny Balwani, from owning blood-testing laboratories for at least two years after determining that Theranos failed to fix problems … Read more

Having helped to contain health insurance costs for working Americans and their children, managed care is now enrolling increasing numbers of Medicare and Medicaid recipients. Among the 20 largest national managed care organizations, for example, 19 serve Medicare enrollees and all 20 include members on Medicaid. In most cases, however, neither program yet accounts for … Read more

It’s not quite a news flash anymore, but the rapid rate of growth in health spending relative to national income is raising concern among policymakers — is the U.S. health care system financially stable? Health care growth is an issue for both private and public payers, with each sector facing similar patterns at least through … Read more

However, the Superstar of Ryan’s proposal-tax credits for Everybody who Has to obtain individual policies irrespective of income-may not move far enough to avoid people from losing policy whilst creating new spending which could benefit highincome individuals that may buy their own medical . That raises the question: Just how severe do this ACA solution … Read more

BIOLOGICS IN DEVELOPMENT Ups and Downs at ASCO 2014 Findings from the huge phase 3 ALTTO trial stole the spotlight at the annual meeting of the American Society of Clinical Oncology (ASCO) in June. The Adjuvant Lapatinib and/or Trastuzumab Treatment Optimisation study (ALTTO) disproved the hypothesis that anti-HER2 therapy with both lapatinib (Tykerb) and trastuzumab … Read more

After her sabbaticalshe moved a few times in order to complete investigate she’d done , and she began contemplating the way she would spend a lot more hours at Prague while keeping up with her Boston-based job responsibilities. Subsequently That the coronavirus outbreak struck. Like lots of other professionals, Braaten found herself running out of … Read more

Pediatric cancer is the stepchild of cancer research when it comes to funding. This is not news to anyone in health care, but when David A. Williams, MD, pointed out the problem in an opinion piece in STAT on April 14, the response was intense. “It seems to have gotten a lot of press coverage,” Williams tells Managed … Read more

New discovery could change ICU care Researchers at the University of Michigan Medical School have discovered that bacteria that normally live in the gut can be detected in the lungs of critically ill patients. The more severe the patients’ illness, the more their usual lung bacteria were outnumbered by the misplaced gut bacteria. The new … Read more

An educated consumer has been a goal in health care of late, cited as one way to tame the health care cost tiger. In the Affordable Care Act, the element most favorable to those consumers is the requirement that health plans provide easy-to-understand benefit summaries, according to the Kaiser Family Foundation. More than 8 in … Read more

Narrow networks mean lower premiums. Now, state insurance commissioners are wrestling with how they should be regulated so that insurers stay solvent and consumers are protected. State legislators and insurance regulators are refereeing the latest power struggle between providers and insurers—the design of provider networks. Insurers are narrowing networks to better control costs; creating “high … Read more

Health care economists and others imagine a society in which managed care had never been invented Frank Diamond Managing Editor Almost everyone has played the “what if” game as in What if World War I had never happened or What if you had married your high school sweetheart. If “what if” ever became a successful … Read more

Demonstrating long-term health improvement for specific populations is one of managed care’s biggest unrealized goals. One group thinks it has the formula.Managing Editor In a perfect managed care world, health plans and physicians would work together toward common goals. Members would make informed choices about use of services. Purchasers would get a clear sense of … Read more

Prepaid Care, Third-World Style: The Uganda Health Cooperative Minnesota-based HealthPartners works with local leaders in a successful initiative to improve health care in a developing African country. Physician Financial Incentives: Another UM Tool Bites the Dust The managed care backlash has claimed another casualty: Financial incentives in physician contracts as a means of controlling utilization. Is … Read more

Please make use of the sharing programs utilized via the talk button on top or side of the articles. Copying posts to discuss with other people is a violation of Mail [email protected] to acquire extra rights. Clients can discuss to 10 or even 20 articles monthly employing the present article support. Novartis is facing legal … Read more

The Weight of the Nation: How Many Rounds Ahead for This Public Policy Fight? 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 … Read more

With videoconferencing, text messaging, email, and the good old phone call, a treatment method that “spent many years in the desert” has now reached an oasis of acceptance—and savings may result.   Sure, Cigna spokesman Joe Mondy is paid to talk about telemedicine—even to sing its praises now that the insurer has a contract with … Read more

Integrated health care systems are seizing the momentum in care coordination from HMOs, says the author of the well-read Internet Healthcare Blog. Health care researcher, consultant, and blogger Matthew Holt says his role “is to support those in the industry trying to look to the near horizon or to those outside health care who want … Read more

Agonist liraglutide to incorporate language at the prescribing information which the medication can decrease risk for major adverse cardiovascular disease, myocardial infarction, stroke and cardiovascular disease in adults who have diabetes and based CVD, based on some news release in Novo Nordisk. The choice relies on results by the LEADER trial, that revealed a 1-3% … Read more

Pneumococcal pneumonia, Caused while the bacterium Streptococcus pneumoniae infects the lungs, which is easily the most common disorder caused by this bacterium from the adults. After the bacterium invades portions of the human anatomy which are free from germs, like the blood or spinal fluid, then the disorder is recognized as”invasive.” “Based To recent advice … Read more

Rich data streams from electronic health records, when used appropriately, can transform population-based care management David Bodycombe Rich data streams from electronic health records, when used appropriately, can transform population-based care management David Bodycombe Predictive modeling (PM) has grown to be a linchpin of care management. Health plans, integrated delivery systems, and other health care … Read more

The Weight Debate Encouraged by employers, health plans ponder expensive options in covering a generation of obese Americans John Carroll Managed Medicaid Business Might Be Worth the Difficulties Financial, regulatory, and access problems continue. Still, this remains a growth industry and some have found a way to profit. Martin Sipkoff Wish List: 10 Things You … Read more

Higher overhead is stifling the growth of physician salaries, say the authors of a new study of physician compensation. From 1996 to 1997, median compensation for all primary care physicians rose a mere 0.42 percent, even lower than the previous year’s growth of 1.42 percent. According to Cejka & Co., a St. Louis health care … Read more

Some potentially good news for consumers, and perhaps the health plans working to keep consumers and employers happy. A study by Express Scripts shows that changing the prescription benefit copayments can reduce costs by encouraging more use of generic drugs. All without shifting costs to consumers. Jake Cedergreen, the director of benefit design and modeling … Read more

Username or e-mail address * Password * Forgot Password? Create new account dfgdgfdgd

A simple idea with huge implications: Let employees purchase their own health insurance with the help of “defined contributions” from employers. Frank Diamond Senior Editor Perhaps only in health care can an idea that’s still very much in the embryonic stage — that’s lacking any grassroots or congressional support to speak of — create such … Read more

Adding a novel monoclonal antibody therapy to traditional chemotherapy increased median survival by nearly a year in patients with advanced sarcoma, a lethal soft tissue cancer. Findings from a multicenter clinical trial of the combination therapy, led by researchers at Columbia University Medical Center and NewYork–Presbyterian, represent the first appreciable improvement in sarcoma outcomes in … Read more

THE FORMULARY FILES Provider-administered drugs move to specialty pharmacy benefit Both payers and providers benefit Krishna Rutvij Patel, PharmD Payers are slowly moving specialty drugs from the medical benefit to the pharmacy benefit to reduce cost. The Pharmacy Benefit Management Institute’s recently released 2014 Specialty Drug Benefit Report calls it an example of a new … Read more

A Barber, a Professor, and an Entrepreneur Walk into a Room: Health Equity and the Strength of Weak Ties Rachel Chong with Freddie Spry at the Lincoln Cottage Assembly. Perhaps, like me, you get invitations to meetings where you’re not convinced it will be time well spent, but you acquiesce nevertheless. Minnesota nice is my … Read more

Name Last modified Size Description Parent Directory 11-Jan-2005 13:10 – dmpaclist.html 01-Jan-2000 12:00 1k 0001.news_pcs.html 09-Apr-2003 23:25 1k 0001.news_texas.html 09-Apr-2003 23:25 2k 0001.news_headlines…> 09-Apr-2003 23:25 2k 0001.compmon.html 07-Jun-2003 12:33 2k 0001.news_iom.html 09-Apr-2003 23:25 2k 0001.news_amap.html 09-Apr-2003 23:25 2k 0001.news_colorado.html 09-Apr-2003 23:25 2k 0001.news_lackcov.html 09-Apr-2003 23:25 2k 0001.dmpac.chartpac…> 09-Apr-2003 23:25 2k 0001.editorsmemo.html 09-Apr-2003 23:25 3k 0001.viral.html … Read more

In Norman Rockwell’s vision, physicians were respected and long-standing members of a community. How much resemblance Rockwell’s depictions bore to reality has always been debated, but Martin/Fletcher finds that certain demographic and economic factors are breaking bonds that once kept physicians in hospitals and/or municipalities for years. The consultant says that about 38 percent of … Read more

For patients having this specific sort of cancer, even Nerlynx could be your first lengthy medical treatment, a sort of therapy that’s taken after a first treatment to lower the probability of the cancer return. Nerlynx is suggested for adult patients that were already treated with a regimen which has the drug trastuzumab. “HER2 Positive … Read more

Once guidelines are embedded in the work flow, it will be much easier to apply them than it is when physicians must essentially take them off the shelf and look them up. A Conversation with James C. Schibanoff, MD When he was 10, Jim Schibanoff watched a physician save his father’s life by correctly diagnosing … Read more

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

There aren’t enough geriatricians to go around, but judicious use of these specialists can still do a lot for an aged population. MargaretAnn Cross Contributing Editor MANAGED CARE March 2005. ©MediMedia USA There aren’t enough geriatricians to go around, but judicious use of these specialists can still do a lot for an aged population. MargaretAnn Cross Contributing … Read more

The rate of increase for medical costs and prescription drugs are projected to decline in 2008, according to the Segal Health Plan Cost Trend Survey. This marks the fifth consecutive year of slower rates of increases for medical claims. Meanwhile, the rise in the costs for prescription drug coverage has slowed at about the same … Read more

Financial, regulatory, and access problems continue. Still, this remains a growth industry and some have found a way to profit. Fifty-nine percent of the nation’s nearly 43 million Medicaid enrollees are part of a managed care plan — a big segment of a demographic group that is younger, fatter, often sicker, and more frequently subject … Read more

STATE INITIATIVES Arizona’s highest court has ruled that utilization review decisions by health plan medical directors are medical–not insurance– decisions and are subject to sanctions by the Board of Medical Examiners.The state Supreme Court upheld without comment a ruling last July by the Arizona Court of Appeals. Writing for the court, Judge Michael D. Ryan … Read more

Orkambi’s Slick Unveiling Puts Insurers in a Bind Makers of this expensive new cystic fibrosis medication manage to sidestep controversy. Health plans may not be as lucky as they weigh cost against value. Value = (Quality + Outcomes) / Cost The search is on for ways to pay for health care that make value more … Read more

Success is relative. Health care costs may have actually decreased year to year during the Great Depression, when deflation was the scourge for a time, but since our records don’t go back that far, it is impossible to say for certain. This year, the rate of increase has slowed, according Segal, the consulting company. That’s … Read more

Frank Diamond The appropriate cliché at the appropriate moment can have an impact. For instance, hearing “the right hand doesn’t know what the left hand is doing” in a hospital might be enough to spin you right back out the revolving door. You know the horror stories. Wrong limb amputated. Forgotten utensils cozying up to … Read more

I have been seeing reports from the Workers Compensation Research Institute (WCRI) about physicians dispensing drugs. That this practice still exists surprises and dismays me. I lived much of my life in New York State, where I had never encountered the practice. I became aware of it only when I was working for a publication that catered … Read more

Fundamental differences in program structure between Medicare and the Veterans Health Administration make drug pricing negotiations problematic We learn on the playground that empty threats are pointless, even dangerous. That’s how some analysts view the possibility of the federal government negotiating Medicare Part D drug prices: virtually a waste of time, but potentially damaging to … Read more

The U.S. Agency for Healthcare Research and Quality will convene the first national conference of state health officials in March, with the intention of defining ways to combat medical and medication errors. The summit grew out of the Institute of Medicine’s report that recommended systematic changes to reduce such errors. IOM says between 44,000 and … Read more

The Competitive New World Of Medicare Managed Care With federal budgets tightening and the ranks of the elderly swelling, the managed care approach is expected to transform Medicare. What will this mean for HMOs, doctors and the treatment of older patients? ‘Prenuptial’ Planning for Your Next Managed Care Contract Signing with a managed care organization … Read more

The only health plan in the country to recover damages from tobacco companies has fought off a court challenge that sought to distribute proceeds from the tobacco settlement directly to policyholders. Blue Cross and Blue Shield of Minnesota reached a settlement with tobacco companies in May. It calls for the insurer to receive $469 million … Read more

Four years Later going on a Sidewalk for Medicaid expansion Founded in Ohio, out going Republican Gov. John Kasich is focused on the near future of the app. Thus he’s currently defending it through a study and throughout the stories of those that have profited from your policy expansion. She says she’d been healthy but … Read more

United HealthCare surveyed 20,000 family physicians, internists and cardiologists in 23 of its health plans to determine how their practice compares with nationally accepted protocols. The project, says United’s chief medical officer, Lee Newcomer, M.D., is not designed to find fault, but rather to provide physicians with information they may be able to use to … Read more

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.

Color charts Also available in PDF Sedgwick Noble Lowndes, a large national employee benefits consulting company, asked more than 30 health insurers and HMOs to list factors they review when planning for increases in health care costs. These respondents estimated how much costs will rise or drop from the year before and why. SOURCE: SEDGWICK … Read more

Free Statins Disrupt Pharmacy Benefit Plans With acquisition costs so low, pharmacies are almost giving away generic statins. How this affects the structure of the pharmacy benefit is yet to be determined.   In its heyday, Lipitor had caché. It was the Gucci or Coach of statins: Patients asked for it by name and physicians … Read more

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 with an … Read more

And metformin hydrochloride, for Firstline treatment of adults who have type two diabetes. With this fresh approval, INVOKAMET® can currently be prescribed in adults who have type two diabetes that aren’t being treated using canagliflozin or metformin and might gain from double therapy. INVOKAMET®, the very first mix of a sodium sugar coworkers — transporter … Read more

New technology is helping health plans address the problems of polypharmacy Martin Sipkoff In the last 18 months, claims data mining by several health plans and pharmacy benefit management companies has led to significant reductions in therapeutic duplication within drug classes, especially statins. Although return-on-investment figures are not yet available — several plans are studying … Read more

The increasing use of electronic records may lead the way toward access to diagnostic rationales and long-range patient treatment histories A recent report by Deloitte Consulting promotes the idea of health plans paying retail pharmacists to serve at the core of disease management programs. The idea is to enhance the role of the pharmacist within … Read more

In one of the most dramatic comebacks in health care, 80% of hospitals and over 50% of doctors’ offices will receive incentive payments this year for installing electronic health record systems that meet government meaningful use standards, according to the Department of Health and Human Services. It was only a few months ago that the … Read more

President Trump said Monday he would talk vaping-industry agents as he chose which will pub earnings of candy, fruit-flavored e cigarettes targeted toward young men and women, increasing concerns among public health urges the step might possibly be diluted. “will be meeting representatives of this Vaping industry, along with doctors and respective nation agents, to … Read more

Bringing Humira (Its Price) Down a Peg The TNF-α blocker is the world’s top-selling drug, by revenue. It faces biosimilar competition in Europe, but it will be four years before it’s challenged in the U.S. Read more A Conversation with Gary Lyman, MD: Biosimilars and the Search for the Cure To Cancer Treatment’s Financial Toxicity … Read more

About 50 of the largest U.S. employers plan to form a health insurance pool for about 4 million part-time, temporary, and contract employees who lack coverage. The pool will also cover early retirees and former employees who have exhausted their COBRA coverage, as well as children of employees who are students but no longer qualify … Read more

Applying Layout Assuming to medical care may enhance innovation, efficacy, and efficacy by boosting attention on provider and patient requirements. The target of this inspection is to establish the best way Design Thinking hasbeen utilized in healthcare and whether it’s beneficial. We Data were accumulated to target end users, medical states, intervention, Layout Thinking approach, … Read more

Back in 1998, we reported about the number of physician executives who held postgraduate business degrees and their median compensation. The number of physician executives with postgraduate degrees has grown since then, and so has their salaries. Today, 18 percent of physician executives who responded to a recent survey by Cejka Search, a health care … Read more

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

The Uberization of American Health Care: Why We Need a Disruptive Model Few examples highlight the differences between the analog and digital worlds as traditional taxi cabs vs. the ride-sharing company Uber. Anand Natampalli In most cities, hailing a taxi means stepping out to the curb and then hoping a driver stops. You take whatever … Read more

HMOs would be wise to use profits from the last six years of growth to position themselves to compete in an altered marketplace. Bob Carlson Contributing Editor Health plans are enjoying some of their best earnings in almost a decade, but there are signs that double-digit premium increases may be coming to an end. In … Read more

Managed care companies generally welcomed the news last month that the deadline for implementing ICD-10 codes had been pushed back by two years. The transition must now occur by Oct. 1, 2013, according to a final regulation issued by the Centers for Medicare and Medicaid Services. “The final compliance dates reflect that CMS understands the … Read more

Magazines sometimes use what we call breakouts or pull quotes — one or two sentences in large type — to give a page more visual interest and to highlight important points in the article. If we had decided to use breakouts in our cover story on the patient-centered medical home, I would have chosen some … Read more

Carolyn M. Clancy, MD, has been appointed director of the Agency for Healthcare Research and Quality. Clancy has served as acting director since the death of John M. Eisenberg, MD, in March 2002. Prior to that, she’d been director of AHRO’s Center for Outcomes and Effectiveness Research…. Kaiser Permanente plans to put all of its … Read more

In their relationships with vendors, employers all too often don’t set expectations for levels of service, adequacy of reports, or how performance will be measured. They are often left with the performance deemed appropriate by the vendor, which may not satisfy them or meet the needs of their employees. Warren Buffet once noted, “Price is … Read more

Steven J. Fox Rachel H. Wilson John W. Jones Jr. Many in health care feared that the de-identification standard under the original Health Insurance Portability and Accountability Act (HIPAA) privacy rule — which would have stripped health information of anything that could reveal a patient’s identity — would curtail important research, health care operations, and … Read more

Though ROI is hard to calculate, insurer says that its on-site clinics are changing employee behavior for the good Frank Diamond When Tufts Health Plan opened its Be Well Center for its own employees in February, it did so as a self-insured company, the kind that tends to rely more on clinics than those that … Read more

References to maximum allowable prices in contracts between plans and PBMs need to be scrutinized, since things are not always what they seem For most of the world, the letters MAC conjure up a Big Mac — the inviting super-sized hamburger that people love but enjoy at their peril. But for health plans providing prescription … Read more

Abstract Purpose: The Oncology Care Model (OCM) is a payment model from the Centers for Medicare and Medicaid Services designed to reduce costs and improve quality in cancer care. Key components of quality for the OCM originate from the 13-component cancer care plan. We surveyed the literature to understand the value of prognosis in OCM-directed planning … Read more

Name Last modified Size Description Parent Directory 04-Jan-98 21:46 – 9704.badfaith.shtml 10-Jun-97 22:44 17k 9704.california.shtml 10-Jun-97 22:43 8k 9704.clancy.shtml 10-Jun-97 22:44 13k 9704.compmon.shtml 10-Jun-97 22:43 1k 9704.contents.shtml 05-Nov-97 09:01 4k 9704.dispute.shtml 10-Jun-97 22:43 16k 9704.editorsmemo.shtml 18-Dec-97 11:08 3k 9704.employer.shtml 10-Jun-97 22:42 7k 9704.ethics.shtml 10-Jun-97 22:44 7k 9704.fraud.shtml 10-Jun-97 22:43 8k 9704.legal.shtml 10-Jun-97 22:44 7k 9704.medicare_satisfy..10-Jun-97 … Read more

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

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

Washington Insight The Medicare+Choice program is in bad shape. Just look at its vitals: Forty-three HMOs in 30 states — including such heavy hitters as Foundation Health Plans, Oxford Health Plans and WellCare Management Group — as well as 22 “demonstration plans” have decided to pull out of the Medicare market before Medicare+Choice debuts next … Read more

Growth in per-capita spending on prescription drugs decelerated in 2000 (though it moved upward again in the first quarter of 2001), compared with 1999, reversing a six-year trend in which spending increases rose steadily from 5.2 percent annually to 18.4 percent. The study cites the spread of three-tier formularies as a possible reason for the … Read more

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

The “fax-back” survey printed on page 24 of Managed Care’s February issue was a small, informal and decidedly unscientific enterprise. That’s fortunate for the administrators of HMOs and other managed care organizations, because the survey’s findings, were they to be upheld by a more rigorous polling process, would be troubling indeed. Perhaps most striking was … Read more

Americans’ girth is growing at an alarming rate. Many are too sedentary, too stressed, suffering from insomnia, making bad food choices. The drumbeat of “We need a culture of health versus a sickness culture” is a refrain that we now often hear and that I have espoused. Yet we advance this form of health and … Read more

Researchers examined data from 20 clinical trials regarding using anti-cytokine medication to treat autoimmune disorder, where esophageal symptoms were quantified as a second results. They discovered that depressive symptoms increased patients, no matter any improvement in physiological symptoms. “Anti-cytokine drugs appear to provide treatment results from the assortment of small-to-moderate effect sizes, that will be … Read more

Somebody’s doing something right. The Centers for Disease Control & Prevention saw a significant drop in death rates in 2011 for 5 of the 15 leading causes of death. There was a major decline in 3 of the top 5 causes of death: heart disease, cancer, and stroke…. Visits to Doctors increased in 2012, according … Read more

Some of all Anthem’s funds goes toward encouraging providers’ telehealth solutions, quality-based apps and personal safety gear. For innetwork dental services, Anthem provides $10 of $ PPE charge per patient, each trip, from June 15 before close of August. There’ll be additional funds for primary care and multi-specialty centers which are coping with financial pressure … Read more

Apps will begin to be prescribed by physicians by the end of this year. Call it disruption, innovation, or crossroad, but it will be here and the question is are we ready for it? WellDoc has been selling type 2 diabetes apps, and will now be the first to launch a prescription app. Go ahead … Read more

Compensation increased at a comparatively small rate from 2000 to 2001 for both primary care physicians and specialists, according to the Medical Group Management Association. The rate of increase for all primary care was only 1.2 percent — about half the previous year’s change, and one third of the 3.4 percent increase in 1998-99. The … Read more

New Hampshire Health and Human Services Commissioner Terry Morton released a plan designed to achieve universal health coverage. The plan, which took three years to develop, is designed to guarantee health coverage and other social services to all residents of the state. The commissioner’s “Guidelines for Change” call for creation of a statewide health insurance … Read more

Name Last modified Size Description Parent Directory 26-Jul-2000 21:05 – ../../../../archiveMC/9711/9711.addyears_large.gif 17-May-2000 12:17 17k ../../../../archiveMC/9711/9711.addyears_small.gif 17-May-2000 12:17 11k 9711.amap.shtml 17-May-2000 12:17 8k 9711.capitation_part..> 17-May-2000 12:17 19k 9711.capitation_part..> 17-May-2000 12:18 17k 9711.capitation_part..> 17-May-2000 12:18 8k 9711.compass.map.gif 17-May-2000 12:18 15k 9711.compass.nationa..> 17-May-2000 12:18 15k ../../../../archiveMC/9711/9711.compass.pdf 17-May-2000 12:19 155k 9711.compass.regions..> 17-May-2000 12:19 28k 9711.compass.reportc..> 17-May-2000 12:19 30k 9711.compass.shtml … Read more

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

Point-of-service plans have been outrunning traditional HMOs in growth rates (48 percent vs. 14 percent in 1995, though they still have only 12 percent of the membership that pure HMOs have) but–funny thing–patients who are in POS plans are a little less likely to intend to reenroll than are their HMO counterparts. In 1995, 75 … Read more

The number of children diagnosed with mental disorders is increasing, bringing with it a $247 billion annual bill, according to a report by the Centers for Disease Control and Prevention. “A total of 13%–20% of children living in the United States experience a mental disorder in a given year, and surveillance during 1994–2011 has shown … Read more

Mount Sinai team looks at major adverse cardiovascular events   August 19, 2016 Full adherence to guideline-recommended therapies is associated with a reduced rate of major adverse cardiovascular events (MACE) as well as cost-savings in patients with cardiovascular disease, according to a new study published in the Journal of the American College of Cardiology. Researchers at … Read more

The United States’ health care system needs consumer and market controls to succeed, but it can’t rely on only those two factors The United States’ health care system needs consumer and market controls to succeed, but it can’t rely on only those two factors Jonathan Weiner wants you to know that, unlike some of his … Read more

Though the title might apply to many aspects of our daily lives and the world as a whole, in this instance I am referring to how Medicare and other insurers interpret the word reasonable to make coverage and payment decisions. A recent editorial in the New England Journal of Medicine highlighted this enduring challenge for Medicare. The authors begin … Read more

DIGITAL EDITION SUBSCRIBEBROWSE PAST ISSUES ISSUE APRIL 2018 Opioid Deaths Among Women Not Getting the Attention They Warrant FRANK DIAMOND Deaths of women from opioid addiction spiked 400%, according to CDC data. Alison Colbert of Duquesne University argues for a gender-specific approach. Social Determinants of Health: Stretching Health Care’s Job Description LOLA BUTCHER Providers and payers are being … Read more

Fruquintinib Shows Fewer Side Effects Than Previous VEGFR Inhibitors China’s equivalent of the U.S. FDA is expected in the coming days to approve fruquintinib, the leading drug from Chinese drug maker Chi-Med, for patients with advanced colon cancer who have already tried two or more chemotherapies. China has never unconditionally approved an innovative drug that … Read more

By Michael J. Folio, J.D. It may sound silly, but managed care contracting is a marriage, a form of medical matrimony. And what do couples do before getting hitched? Date, meet the parents and discuss all those important issues: kids, careers, religion, goals. Likewise, before you don your formal garb and dance down the aisle … Read more

Through the duration of 2018, medication prices kept increasing and outrage about any of this followed near. President Trump was among the loudest voices whining about rising prices on brand name prescription medication along with mail-order cost tags on fresh specialization drugs since they reached the marketplace. And nonetheless the listing of possible repairs issued … Read more

Medicare Part D and the Department of Veterans Affairs (VA) are two major government payers of health benefits that use different approaches to managing prescription drug benefits, and a study that looked at managing brand-name prescription drugs shows a vast difference in efficiency. Walid F. Gellad, MD, MPH, and colleagues reviewed brand-name diabetes medication use … Read more

“pinpointing highrisk classes helps to prevent excessive screening which could be insecure and costly, and also to establish who must be screened and that are an applicant for pre emptive antibiotics or isolation ” CP-CRE, that stands to get carbapenemase-producing carbapenem-resistant Enterobacteriacecae frequently affects patients from hospitals, assisted living facilities and other health settings that … Read more

The subject of physician-patient boundaries illustrates how well-intentioned policy can be written in a way that is simply too shallow to serve the goals of ethics. If you’ve sat on a credentials committee, disciplinary panel, or medical-licensing board, you surely reviewed cases of physician-patient sexual involvement. Our contemporary attitude toward such encounters is to label … Read more

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

An insurance framework proposed by the Commonwealth Fund includes a national insurance exchange that would offer both private insurance plans and a new public plan option “that would achieve near-universal coverage.” The report estimates that premiums for the public plan option would be at least 20 percent below those currently available for a comparable package … Read more

Predictive Modeling & Genomics: Marriage of Promise and Risk Integration of predictive modeling and genomic tools means improved technology, enhanced databases, and appropriate legal guidance. The integration of predictive modeling and genomic research is inevitable, emerging as a marriage that can improve the quality of care and help control costs through prevention and intervention. It … Read more

Employers Roll Up Their Sleeves No longer passive, companies are working in a variety of ways to improve employees’ care. Are health plans being left behind? Evidence-Based Medicine Is Not Enough Although EBM is only just getting started, many people are looking beyond evaluating treatments head to head and considering cost as well Bringing Guidelines … Read more

The Congressional Budget Office came out with its much-anticipated report on the American Health Care Act (AHCA) on Monday, and the call on how many Americans will be without health insurance surpasses what pundits had been reading in the tea leaves. While the CBO’s projection of 14 million people losing coverage in 2018—the year of the … Read more

Health plans can expect to pay less in dues, but whether the new organization will have increased influence with legislators remains to be seen. On Capitol Hill, numbers are important. For the lobbying organizations that want to influence Congress, they’re an essential factor in the political formula used to evaluate status and influence. So when … Read more

Malarial Organisms Traced to Age of Dinosaurs Deadly disease may have shaped animal evolution on Earth, scientist says   A new analysis of the prehistoric origin of malaria suggests that it evolved in insects at least 100 million years ago, and that the first vertebrate hosts of the disease were probably reptiles, which at that … Read more

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

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

The simple idea behind healthcare is the different businesses in medical insurance and maintenance strategy interact to boost the wellbeing of their community people by incorporating services and tackling the root of ill health and fitness. It marks a change from Policies which have supported rivalry towards a method that centers upon cooperation between different … Read more

John Marcille We’re all time travelers. It’s just that we only move forward and, not to get gloomy, for only a relatively short span. We don’t go back. If we could we might — out of curiosity — leap 3,800 years to when Babylon’s King Hammurabi issued his code for physicians. This is the subject … Read more

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

The nation is in an uproar over rising medical costs, and much of the problem is excess or inappropriate utilization Last year an article appeared in the Journal of the American Medical Association whose title says it all: “The Perfect Storm of Overutilization.” The lead author was Ezekiel Emanuel, MD, PhD, of the department of … Read more

Joseph Burns Contributing Editor As they prepare for health reform, many health plans are investing in primary care. WellPoint bought the Medicaid managed care plan CareMore, for example. UnitedHealthcare bought Monarch, a large physician group practice. Those health plans that do not acquire a large provider group are developing virtual networks, says Charles Kennedy, CEO … Read more

Ophthalmologists and optometrists are united in opposing participation by stand-alone benefit payers In the world of health care benefits, vision plans barely register on the radar. The word “vision” appears twice in the 906-page final draft of the Patient Protection and Affordable Care Act (PPACA), and the phrase “vision care” only once. These very brief … Read more

MANAGED CARE November 1999. ©1999 MediMedia USA RIGHT TO SUE The adage “all politics is local” may, in the end, become the motto that sinks ERISA. HMO executives should assume protection will evaporate. Allen Briskin Gerry Hinkley In the coming months, a House-Senate committee will debate whether the next Patients Bill of Rights should give health plan … Read more

Fortune 500 employers are ready to shed old benefit models for “managed consumerism” MargaretAnn Cross Contributing Editor Fortune 500 employers that are increasing health plan deductibles, adding coinsurance, and putting incentives in place to encourage employees to embrace healthy lifestyles are getting more involved in the details of health plan benefit design than they have … Read more

Has the gatekeeper system forced primary care physicians to treat patients with illnesses that are complex beyond their expertise? A quarter of primary care doctors worry about the care some of their sickest patients receive because, they say, in some cases it might be better delivered by a specialist. In the New England Journal of … Read more

The United Kingdom’s National Health Service came under fire recently when it chose one vaccine to prevent cervical cancer over a rival. The vaccine program, which will protect young girls who might develop cervical cancer later in life, will dispense Cervarix, a vaccine that offers immunity to human papilloma virus (HPV) types 16 and 18, … Read more

Washington Insight The Clinton administration officially buried its most ambitious piece of domestic legislation, the Patients Bill of Rights, Oct. 7. On that day, during a meeting with Hungarian Prime Minister Viktor Orban, President Clinton declared: “This Congress killed campaign finance reform, the minimum wage, tobacco legislation, even killed the Patients Bill of Rights.” But … Read more

The therapy is regarded as a 20 mg pill, once per day, with or without food. “MS is a Intricate disorder, and some other person’s reaction to MS Disease-modifying therapy may differ. Ponvory, manufactured by Janssen, functions regulating sphingosine-1-phosphate indicating. That really is thought to”trap” immune cells from lymph nodes, therefore it’s impossible for them … Read more

Only about 35 percent of girls get the full three doses of the vaccine for the human papillomavirus, which causes most cervical cancers Joseph Burns Contributing Editor Only about 35 percent of girls get the full three doses of the vaccine for the human papillomavirus, which causes most cervical cancers Joseph Burns Contributing Editor The … Read more

The use of prescription sleep aids by 18- to 24-year olds nearly tripled between 1998 and 2006, according to medical and drug claims data from the Thomson Reuters MarketScan Research databases. During that period, the average length of time sleep aids were used by adults under age 45 increased by more than 40 percent — … Read more

Independence Blue Cross teams up with the American College of Physicians to create an online program that facilitates creation of medical homes Frank Diamond In the excitement over the focus on the patient-centered medical home (PCMH), some physicians murmured a question that might not have been heard: Exactly how does one build a PCMH? Michael … Read more

Teresa B. Gibson, PhD Thompson Reuters (Healthcare) Inc. Yonghua Jing, PhD Bristol-Myers Squibb Edward Kim, MD, MBA Eisai Inc. (formerly Bristol-Myers Squibb) Erin Bagalman, MSW Thomson Reuters (Healthcare) Inc. Sara Wang, PhD Thomson Reuters (Healthcare) Inc. Jalpa A. Doshi, PhD University of Pennsylvania School of Medicine Full text in PDF ABSTRACT Purpose: To assess the relationship … Read more

Along with greater precision, they could bring opportunities to coordinate the efforts of health plans and PBMs Biomarkers are unquestionably the most compelling topic in rheumatoid arthritis right now. Just this past June, at the annual meeting of the European League Against Rheumatism (EULAR) in Madrid, they were the focus of an unprecedented number of … Read more

The pharmacy profession continues to pay well, though where somebody practices has much to do with just how well, according to the 2004 Pharmacy Compensation Survey — Spring Edition by Mercer Human Resource Consulting. Pharmacists saw an average increase from 2003 to 2004 of 5 percent. Nationally, staff pharmacists were paid a median total cash … Read more

As the number of onsite clinics at factories and office parks expands, will employers start to think they don’t need managed care contracts? When Toyota opened a $1.23 billion truck manufacturing plant in San Antonio in 2006, the company sought a laudable level of productivity from employees and onsite suppliers, the independent companies that sell … Read more

Name Last modified Size Description Parent Directory 01-Mar-2005 11:31 – 0005.broker.html 09-Jun-2003 11:44 17k ../../../archives/0005/0005.compmon.gif 01-May-2000 12:00 34k 0005.compmon.html 09-Apr-2003 23:33 2k ../../../archives/0005/0005.compmon.pdf 01-May-2000 12:00 36k 0005.conf.html 09-Jun-2003 11:44 8k 0005.contents.html 09-Apr-2003 23:33 3k ../../../archives/0005/0005.cover.jpg 01-May-2000 12:00 12k 0005.news_arizona.html 09-Apr-2003 23:33 2k 0005.news_fudge.html 09-Apr-2003 23:33 2k 0005.news_headlines…> 09-Apr-2003 23:33 2k 0005.news_latest.html 09-Apr-2003 23:33 3k 0005.news_prescrip.html … Read more

Kaiser Permanente has launched a computerized surveillance system designed to alert public health officials to possible disease outbreaks. “It will be an extremely efficient way to monitor bioterrorism,” Eric Koscove, chief of the emergency medicine department at Kaiser Permanente Santa Clara, tells the Contra Costa Times. The Internet-based system, which was developed at Sandia National … Read more

Insurers feel pressure to incorporate new agents into their drug benefit, but evidence of effectiveness is questionable The diabetes results are pouring in. Study after study shows that pharmacist-led medication therapy management and other interventions increase adherence and lower HbA1C levels. While these goals are important, they may miss the boat in terms of the … Read more

Many experts predict that there will be a dearth of primary care doctors, but others are not so worried In response to warnings of a significant physician shortage, allopathic medical schools are expanding enrollments by more than 20 percent, and osteopathic schools are growing even faster. However, a cap on graduate medical education funding and … Read more

The Problem With Our Health Care Cost Crisis? Hint: It Has Nothing to Do With Providers John Sung Kim As an executive at a leading health technology company in San Francisco, I often view both patients and medical providers as a bit whiny. As they rail against “Obamacare” or “intolerable patient families,” I’m often thinking, … Read more

Introduction According to 2014 statistics from the CDC, diabetes affects 12.6% of the US adult population (CDC 2016), and of those individuals, fewer than half are deemed to be at their treatment goal (ODPHP 2016). Both patient-related and provider-related factors contribute to observed suboptimal outcomes. Patient-related factors include high out-of-pocket treatment costs that contribute to … Read more

It happens over and over. Somebody has a clever idea for a system that will promote better care and/or lower cost. The health care system as a whole embraces the system, uses it for a while and then finds problems that were not envisioned, or were minimized. Global capitation encourages primary care doctors to tackle … Read more

Volume-based maintenance denotes the payment that a healthcare provider receives services that a patient may possibly want. The sort of service and high quality of service really doesn’t change lives at the total amount a provider may possibly receive. That really is volume-based maintenance in summary, which may be called a feeforservice care. All incentives … Read more

Patients with heart disease bucked expectations in this study by using the Internet to compensate for their lack of mobility. By Stephen Robitaille A long-held axiom in the world of computers has been that the information age belongs to the young. Since the 1980s, when studies first showed that older managers were less likely than … Read more

Name Last modified Size Description Parent Directory 28-Aug-2000 11:10 – ../../../../archiveMC/9711/9711.addyears_large.gif 17-May-2000 12:17 17k ../../../../archiveMC/9711/9711.addyears_small.gif 17-May-2000 12:17 11k 9711.amap.shtml 17-May-2000 12:17 8k 9711.capitation_part..> 17-May-2000 12:17 19k 9711.capitation_part..> 17-May-2000 12:18 17k 9711.capitation_part..> 17-May-2000 12:18 8k 9711.compass.map.gif 17-May-2000 12:18 15k 9711.compass.nationa..> 17-May-2000 12:18 15k ../../../../archiveMC/9711/9711.compass.pdf 17-May-2000 12:19 155k 9711.compass.regions..> 17-May-2000 12:19 28k 9711.compass.reportc..> 17-May-2000 12:19 30k 9711.compass.shtml … 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 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 usual network … Read more

Putting a price on a priceless occupation is tricky to perform, but we gave it a go anyway. The pioneer in reimbursement data, analytics and planning, would really like to honor most of the Moms out there that work their hardest day-in along with dayout. We’d want to comprehend both stay-at-home and professional Mothers in … Read more

QUALITY MEASUREMENT It’s long been said that PPOs, by their varied nature, can’t be held to the same quality yardsticks as HMOs. Yet, in time, something will have to suffice. Michael Levin-Epstein Contributing Editor There are more Americans enrolled in PPOs than in HMOs and indemnity coverage combined. Yet while HMO performance largely has been … Read more

Tezacaftor/ivacaftor along with ivacaftor for its treating this root reason for cystic fibrosis in patients aged 12 or older that have two copies of their F508del mutation in the cystic fibrosis transmembrane conductance regulator enzyme, or who’ve 1 hereditary mutation that’s receptive to treat tezacaftor/ivacaftor. Medication maker Vertex has declared that the FDA has accepted … Read more

MEDICATION MANAGEMENT Health insurers’ capability to gather and create data far outstrips their ability to analyze the information and put it to use. Progress is being made. Big data is a big deal, or so the health care IT vendors say. As revenue from the sale of electronic health records falls off and complaints soar … Read more

How Rebates, Copayments, and Administration Costs Affect the Cost-effectiveness of Osteoporosis Therapies Using case studies, researchers assess the effect of rebate rates on the cost-effectiveness of two oral bisphosphonates that are competing for tier 2 positioning Nicole C. Ferko MSc Director, Cornerstone Research Group, Burlington, Ontario Natalie Borisova PhD Health Economist, P&G Pharmaceuticals Inc. Parisa … Read more

NuView Life Sciences fuses molecular biology with imaging technology using the radioactive nuclide Copper 64 A recent television mystery show I was watching had many people searching for a suspect without success — that is, until the authorities brought in a bloodhound to “sniff” out the suspect. The dog took them on an entirely new … Read more

An Easy and Profitable Way to Turbocharge Disease Management? When an employer group shifts from one health plan to another, why not allow them to take their claims data to the next health plan? That way, the new plan would gain immediate knowledge of the specific disease burden faced by its new members and be … Read more

This Employee Benefit Research Institute official sees little change in the level of health benefits so long as unemployment remains low Linkedin Share Button (link is external) Tweet Widget (link is external) Share on Facebook (link is external) Google Plus One (link is external) MANAGED CARE April 2006. ©MediMedia USA This Employee Benefit Research Institute … Read more

The endorsement creates Yescarta the very first chimeric antigen receptor (CAR) tcell therapy approved for patients with indolent follicular lymphoma, follows FDA break through Therapy Designation and also a priority inspection, also marks the 3rd approved sign to get a Kite cell therapy. The approval is based on results in ZUMA-5, a single-arm, open-label study … Read more

FEATURE Could QALYs Help in Assessing High-Priced Cancer Treatments? Other nations use ‘quality-adjusted life-years’ to measure the cost-effectiveness of drugs, but this tool has been anathema in the United States — so far Jack McCain Also available in PDF For doctors at Memorial Sloan-Kettering Cancer Center in late 2012, it was an easy call. The … Read more

Nearly half of the nation’s academic medical centers are being punished through one of the federal government’s sternest attempts to promote patient safety, according to a report from Kaiser Health News (KHN). Medicare is reducing a year’s worth of payments to 758 hospitals, including some of the most prestigious teaching hospitals in the country, with the … Read more

Whereas before insurers used to devise new products and processes to attract purchasers, now more and more employers are going to the plans and insisting on preventive care Employers may indeed be shifting insurance costs to employees, but many are also taking greater interest in their workers’ health. Encouraged by public health officials, these employers … Read more

Banning Indoor Smoking Helps Kids With Asthma Researchers in Britain recently published a paper in Pediatrics showing a dramatic swing in admissions for childhood asthma after indoor smoking was banned by the British in 2007. A hospitalization trend that had been steadily around 2% fell to minus 9%. The trend was sustained.  10.1542/peds.2012-2592 I’m wondering, … Read more

MANAGED CARE September 1999. ©1999 MediMedia USA For the first time, the National Committee for Quality Assurance says it can demonstrate a strong link between clinical quality, as reported in HEDIS, and member satisfaction. Plans that scored in the highest quartile last year on “effectiveness of care” measures in HEDIS, NCQA’s vehicle for HMO-quality measurement, also received … Read more

Don’t look now payers, but expect to be double-teamed by hospitals and physicians. With Medicare payments and the Prospective Payment System getting squeezed, the biggest revenue stream for both hospitals and physicians is — wait for it — you. And the need for hospitals and physicians to collaborate on care management to reduce costs is … Read more

Two of the country’s leading nonprofit HMOs, Kaiser Permanente Northwest and Group Health Cooperative of Puget Sound, will be working more closely together than ever before, with an actual merger among the possibilities, officials of the companies have announced. The boards of directors from both companies could reach a decision by November. The combined company … Read more

Chest X-rays do not save lives when used to screen for lung cancer, according to a 20-year study reported in the Journal of the National Cancer Institute. Mayo Clinic/NCI researchers found that imaging led to no reduction in mortality, but revealed many “clinically insignificant” tumors, inviting potentially unnecessary treatment…. “California, open your Golden Gate?” Only … Read more

Top pay-for-performance programs point to increased focus on hospital incentives, efficiency measures, coordination, and standardization Hospitals in New Jersey have received rewards from the savings that come from improving performance in areas such as treating heart attack victims under a program launched last summer by Horizon Blue Cross Blue Shield of New Jersey. The statewide … Read more

In the past, reducing demand for care by raising patients’ costs has resulted in the loss of some needed care. Can we avoid the trap? MargaretAnn Cross Contributing Editor When customers began walking away from the prescription counter without their medications because they’d been surprised by a high copayment, Bridget Olson, PharmD, began to get … Read more

In theory, ACOs are groups of providers that band together to lower the cost of health while maintaining its quality by using various tools in the value-based care (aka population health) toolkit: care coordination, data analytics, avoidance of low-value services. But a study published in this month’s issue of Health Affairs possibly—it is open to several interpretations—paints a … Read more

For 30 years, Judy Spelman had a front-row seat on the daily drama of hospital life — much of that time working as an emergency room nurse. But as California’s walking wounded passed through her care, some stood out. Like the kids who came in to the ER with pneumonia that started as a head … Read more

NEWS AND COMMENTARY Agreeing that antagonism gets you nowhere, the AMA and the Blue Cross Blue Shield Association have developed guidelines for improving relations between physicians and health plans. The AMA will distribute the recommendations to its members, while BCBSA will work with chief medical officers of its 45 plans to put them into practice. … Read more

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

Bob Carlson MANAGED CARE May 2001. ©MediMedia USA True, the rest of the country doesn’t always follow California’s lead. But you’d probably be right if you viewed the California Public Employees’ Retirement System’s April deal with eight HMOs as an omen. Long considered a bellwether, CalPERS is the nation’s largest public pension fund. Its health contracts for … Read more

Facing significant increases in health-benefit costs, employers appear less willing to bite the bullet than in the past — and are passing many of those increases on to workers. As the cost of coverage crept upward during the last three years, a tight labor market and recruiting pressures led many companies to shield employees from … Read more

The Health Care Financing Administration has given Medicare+Choice plans an extra two months to decide benefit packages and pricing for 2000, extending the deadline from May 1 to July 1. Last year, plans complained that the May 1 deadline didn’t give them time to determine current-year trends — forcing many to abandon Medicare. Meanwhile, the … Read more

Now Might Be the Right Time To Kill Hospital Value-based Purchasing Program No real trends in quality improvement or cost savings have emerged, while mortality outcomes have remained flat. With so little money at risk, the program simply may not turn enough heads. It was the first pay-for-performance program launched by the ACA and the … Read more

A coalition of the country’s largest employers said health care coverage and retirement plans for American workers should be delivered by third-party administrators such as banks, investment companies, and insurers. That’s the recommendation made by the ERISA Industry Committee (ERIC) in its “New Benefit Platform for Life Security” report. Although employers would continue funding health … Read more

Programs that cover the costs of basic medical care are there for the asking for parents in low-income families whose children need it. Too often, however, aid is not requested. According to the Urban Institute, of the estimated 8.2 million children who lacked health coverage at the beginning of 2002, 4.7 million are eligible for, … Read more

Sen. Ron Wyden’s bill promises to provide universal coverage without draining the federal treasury. Too good to be true? A universal coverage plan that has been gradually gaining the support of senators cleared a major obstacle recently, winning an opinion from the Congressional Budget Office that it could actually generate budget surpluses after it becomes … Read more

The debate among state legislators and managed care regulators about coverage of Viagra, Pfizer’s popular anti-impotence medication, continued on two fronts last month. A number of states rejected a federal order that Medicaid programs cover the drug. And legislators in California called for an investigation of commercial health insurers that have decided not to cover … Read more

Premera Blue Cross and a large Spokane oncology practice agree on treatment protocols and on the importance of cost control As the cancer-treatment landscape changes — promising longer, healthier lives for patients but with the side effect of astronomical costs — most health plans and oncologists are locked in a stare-down to see who has … Read more

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

Knowledge that oral health may affect overall health is prompting some plans to act Managed care is coming to mean prevention, a feel-good, cost-cutting method that improves and lengthens lives. So recent interest among insurers in how dental health affects overall wellbeing is not surprising. Plans are acting on the evidence, too — such as … Read more

Into the debate about the frequency of cancer screenings steps the Gallup Organization, whose survey shows that a majority of Americans are satisfied with how often such screenings occur. Fifty-eight percent think that Pap smears, mammograms, and other screening tests are performed often enough. Thirty-one percent say they are not done often enough, while 7 … Read more

Name Last modified Size Description Parent Directory 11-Jan-2005 13:10 – 0003.washington.html 09-Apr-2003 23:29 8k 0003.states.html 09-Apr-2003 23:29 8k 0003.qna_jessee.html 09-Jun-2003 11:44 19k ../../../archives/0003/0003.percut.table1b.gif 01-Mar-2000 12:00 42k ../../../archives/0003/0003.percut.table1a.gif 01-Mar-2000 12:00 68k ../../../archives/0003/0003.percut.pdf 01-Mar-2000 12:00 118k 0003.percut.html 09-Apr-2003 23:29 25k 0003.pbmeval.html 09-Jun-2003 11:44 11k ../../../archives/0003/0003.pbeval_chart2.gif 01-Mar-2000 12:00 28k ../../../archives/0003/0003.pbeval_chart1.gif 01-Mar-2000 12:00 8k ../../../archives/0003/0003.outlook.pdf 01-Mar-2000 12:00 43k 0003.outlook.html … Read more

Highmark, the combined Blues plans of Western and Central Pennsylvania, recovered $3.6 million from physicians and other providers during 1997 through retrospective utilization review. Highmark’s process of retrospective UR is aided by software that analyzes irregularities in claims patterns, which are then investigated. Highmark says most cases involve billing errors rather than fraud…. Kaiser Permanente … Read more

By Frank Diamond Senior Editor It’s perhaps ironic that Minnesota, where the wind roars off Lake Superior with all the force of a full-body slam, has provided the habitat to let a “plant” like direct contracting grow. This is where, in 1997, the Buyers Health Care Action Group, a 47-member employer consortium, decided to bypass … 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

Whereas before insurers used to devise new products and processes to attract purchasers, now more and more employers are going to the plans and insisting on preventive care   Employers may indeed be shifting insurance costs to employees, but many are also taking greater interest in their workers’ health. Encouraged by public health officials, these … Read more

Combining Medicare fee-for-service payments with new incentive programs could help physician groups save money for Medicare and reach quality-of-care targets, according to the February 2008 Medicare Physician Payment report issued by the Government Accountability Office. The Centers for Medicare & Medicaid Services undertook a pilot program involving 10 physician group practices with more than 200 … Read more

The Weight of the Nation: How Many Rounds Ahead for This Public Policy Fight? Submitted by Paul Terry on Wed, 2012-05-16 14:42 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 … Read more

JAK1/JAK2 inhibitor targets inflammatory and autoimmune diseases A new drug application (NDA) has been submitted to the FDA for the approval of oral once-daily baricitinib (Eli Lilly/Incite Corporation) for the treatment of moderately to severely active rheumatoid arthritis (RA). Baricitinib is the only once-daily oral selective Janus kinase-1 (JAK1) and JAK2 inhibitor currently in late-stage … Read more

Don’t expect politicians to ride to the rescue, says the author of a book that examines just what went wrong and how we can fix it. He puts his faith in entrepreneurs, among others. Marty Makary, MD, is a surgeon and professor of health policy at Johns Hopkins. But for two years, he ventured out … Read more

Physicians and their charges have different ideas about what makes for good cancer care. Patient surveys help, but they need to be handled right.   Patient-centered quality measures may be a “scary black box” to many physicians, says Colleen McHorney, PhD, one of the leaders of a study measuring patient expectations. What is quality in … Read more

BY MICHAEL D. DALZELL Senior Editor Charts:   PPOs catching up with HMO/POS plans Benefit plans: a cost comparison Sidebar: Liability’s effect on PPOs Sidebar: PPOs less likely to tumble than POS plans It wasn’t that long ago that people who sold health coverage touted the HMO as the end point for managed care. They persuaded brokers and employers … Read more

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

In a Era of Ultra Modern Hightech Apparatus Which are All Worthy of Display time In a large budget Hollywood action picture, an individual may possibly be astonished to detect that an extremely”un-glamorous” and basic medical apparatus will be made from the Combat Casualty Care Research Program of their U.S. Army Medical Research and Materiel … Read more

Despite a widening gap between the expense of HMO and PPO plans, more employers than ever offer PPOs — and their employees are taking them up on it. Nationwide, the share of people who have employer-sponsored insurance and who are enrolled in PPOs rose 3 percentage points from 1998 to 1999, while the share enrolled … Read more

It seems some folks have been publishing on the Internet pictures of women visiting abortion clinics. Is this constitutionally protected journalism? Or a violation of privacy? Everyone understands that this tactic is intended to harass and intimidate people connected with abortion activities. Abortion opponents view this as nonviolent action aimed at discouraging an abhorrent social … Read more

It’s not often in this town that you find the chief of the Health Care Financing Administration, the president of the Health Insurance Association of America, the head of the American Association of Retired Persons, Democratic Sen. Tom Harkin, and Republican Sen. Phil Gramm all singing from the same page. But that’s exactly what’s happening … Read more

A special panel hopes to push providers toward a global payment system that focuses more on outcomes Seven years ago, when Massachusetts passed its big health care reform bill aimed at universal coverage, lawmakers left out one very noticeable element. There was no effort to rein in prices. At the time, a number of industry … Read more

Cases by some policymakers that the Federal health care program is approaching “liquidation” are exceptionally deceptive. In spite of the fact that Federal health insurance faces financing difficulties, the program isn’t very nearly chapter 11 or stopping to work. Such charges address misconception of Government health care’s accounts. The 2019 report of Federal medical care’s … Read more

Patients with high cholesterol who regularly take their statins have significantly fewer hospitalizations from cardiovascular problems and can reduce their health care costs by as much as $944 over 18 months, says a study from the American Journal of Cardiology. Lead author Donald G. Pittman, PharmD, of the Medco Research Institute and colleagues reviewed claims … Read more

NEWS AND COMMENTARY HCFA: Medicaid Must Now Cover Growth Hormone The Health Care Financing Administration has ordered Medicaid to cover Serostim, a growth hormone that can stifle cachexia — also known to AIDS patients as wasting…. Two New York representatives have introduced a measure in Congress that would require health plans to cover routine breast, … Read more

Advance Paradigm will buy PCS Health Systems from Rite Aid Corp. for $1 billion — a third less than what Rite Aid paid for PCS last year…. In Massachusetts, supporters are working with the legislature on a compromise after gaining enough signatures to put a universal care proposal on the November ballot. But in Washington … Read more

Long-term care insurance could help defuse the looming baby boom retirement ‘disaster’ Caregivers Fill Crucial Role But Don’t Get Much Help Their care of loved ones defrays costs that would otherwise have to be borne by the health care system, but they too often go it alone. Departments CANCER WATCH Bring the Cancer Moonshot in … Read more

Abstract Purpose: To evaluate gastrointestinal (GI)-related and irritable bowel syndrome (IBS)/constipation-related health care resource use (HCRU) and costs following linaclotide treatment initiation among U.S. commercially insured (commercial) and Medicare Advantage with Part D (Medicare) patients. Design: Patients age ≥18 years with ≥1 pharmacy claim for linaclotide between December 2012 and June 2013 were identified using … Read more

The FDA has Already Approved a supplemental new drug application in Omeros To enlarge the sign for Omidria for use in pediatric patients, based on a company news release. Omidria averts intraoperative miosis and reduces post operative pain throughout cataract operation or IOL replacement. An extra six weeks of U.S. economy exclusivity to get Omidria, … Read more

Independence Blue Cross teams up with the American College of Physicians to create an online program that facilitates creation of medical homes In the excitement over the focus on the patient-centered medical home (PCMH), some physicians murmured a question that might not have been heard: Exactly how does one build a PCMH? Michael S. Barr, … Read more

When it comes to pay-for-performance programs, physicians view them with “deep suspicion,” says Bill Steiger, editor of the Physician Executive, the journal of the American College of Physician Executives. He bases this assertion on results of a recent national poll undertaken by the association. The survey showed that physicians “are not convinced the payment systems will … Read more

Stories about underdogs (David and Goliath, Rocky, the 1969 Mets, the 2008 Barack Obama) are as much about overconfidence as they are about confidence. Yes, the challenger is scrappy. The favorite, on the other hand, needs just enough hubris to make his or her downfall ensure that the lesson resonates with every would-be David and Goliath … Read more

Today, almost all major companies have completed the shift from indemnity insurance to managed care. By 1999, only 11 percent of employees at Fortune 500 companies were still enrolled in indemnity plans, with the vast majority being covered by some form of managed care (see “Holding on to a lead” below). According to health care … Read more

BY NEIL CAESAR, J.D. As health care reform continues to reshape the way medical services are delivered, physicians will find it important to choose carefully the alliances they join and the managed care arrangements in which they participate. Previous columns have discussed the likelihood that health reform will push physicians toward seeking the best alliances … Read more

Employers want to do everything within the law to make workers change their lifestyles, and they expect health plans to help Wellness It must have seemed like a pretty good idea at the time. Tribune, owner of newspapers and other media outlets, launched a program this year in which employees and any of their dependents … Read more

Abstract Purpose: To evaluate gastrointestinal (GI)-related and irritable bowel syndrome (IBS)/constipation-related health care resource use (HCRU) and costs following linaclotide treatment initiation among U.S. commercially insured (commercial) and Medicare Advantage with Part D (Medicare) patients. Design: Patients age ≥18 years with ≥1 pharmacy claim for linaclotide between December 2012 and June 2013 were identified using claims data … Read more

Sensing an invasion of their territory, MCOs are jumping into a market forged by a group of upstarts. The development renews a fundamental debate about the juxtaposition of consumer involvement, cost containment, cost shifting, and quality of care. Michael D. Dalzell Managing Editor Dalton, Ga. is a town built on carpet. Some 80 percent of … Read more

Spondylocostal dysplasia Ribs might be sanded or lacking chaotic patterns. Some babies might have difficulty breathing due to a low size of their thorax. The thorax is the middle section of the human body extending from the neck into the abdomen and for example the torso cavity. Some times, breathing difficulties might be life-threatening and … Read more

Young girls who receive the vaccine Gardasil for human papillomavirus are no more prone to become pregnant or infected by sexually transmitted diseases than girls who do not receive the vaccine, according to a study in the journal Pediatrics. “We present the first evaluation of sexual activity-related outcomes after adolescent HPV vaccination in the recommended … Read more

Use apps to keep patients connected to the health care system during transitions and in between visits. At the oft-brittle point of contact between health insurer and patient, Harvard Pilgrim Health Plan places an app. Launched at the end of June, it allows patients—most of whom have been recently discharged from the hospital—to connect with … Read more

As Monetary Democrats consider just how much visit expand health care, a new survey indicates greater than half of respondents are in support of a”Medicare for All” singlepayer plan or some public medical insurance coverage option — they largely like the latter. Overall, 55 per cent of respondents said that they encourage Medicare for everybody, … Read more

Competitors are coming together to see if they can leverage blockchain’s magic to solve big problems. Provider directories are among the first use cases. Mike Jacobs works in technology engineering at Optum, UnitedHealth Group’s technology and health care services unit. Kyle Culver has a similar job at Humana. UnitedHealth and Humana are competitors, but now … Read more

What Makes Harvard Pilgrim So Good? It’s the nation’s leader in member satisfaction and quality of care, according to NCQA. Dynamic leadership and dominance of a region where excellent docs and plans abound are part of the formula. About 25 years ago, Toyota introduced a quality control system that revolutionized manufacturing. Some 70 years before … Read more

For the new director of the Center for Outcomes and Effectiveness Research at the federal Agency for Health Care Policy and Research, putting in one night a week as a practicing internist is a helpful reality check. An Interview with Carolyn Clancy, M.D. On March 3, Carolyn M. Clancy, M.D., was named director of the … Read more

Statin selection has just become more complicated. Will physicians be diverted from interventions that may be less costly and just as effective? Jack McCain Contributing Editor Full text of this article is available in PDF. When Gertrude Stein famously wrote, “Rose is a rose is a rose is a rose,” she seemed to reveal an ignorance … Read more

When I entered practice in 1976, I began with the philosophy that if a test was important enough to do for my patients, its results were important enough to report to them–even if the results were normal. I thought about how I might be the one anxiously awaiting the results of a test performed to … Read more

Angiogenesis blockade is a 30 year old concept, but it will soon make the leap from lab bench to pharmacy shelf. Thomas Morrow, MD A new class of drugs that blocks the growth of a tumor’s blood vessels will soon become available in the United States — and, at the same time, will define a … Read more

Adverse drug reaction increases six-fold from the second decade to the eighth decade of life, from 10 adverse events per 10,000 persons to 60 per 10,000. This is especially important to oncology patients. J.F. Knudsen, PhD, MD, a research associate at New Hope Cancer Center in Hudson, Fla., and other researchers performed a retrospective cohort … Read more

4 Steps to Boost Your Medicare Star Ratings and Retain Your Customers   A distinct correlation has been found between the number of complaints about Medicare Advantage plans and the number of customers withdrawing from these plans. Here are four steps health plans can take to reduce customer complaints, improve Medicare star ratings, and lower … Read more

Optum’s Lisa Tseng Keeps Entrepreneurial Ball Rolling FRANK DIAMOND The 37-year-old has a title: executive vice president of Optum. But she wears many hats, including running a division that sells affordable hearing aids that cost from free to $599 for UnitedHealthcare members. Non-plan members can get similar hearing aids for up to 70% less than … Read more

Cover Story When Giants Stumble Aetna U.S. Healthcare and Kaiser Permanente have taken some financial hits recently. Their corporate cultures have changed as a result. The “new” Kaiser and Aetna face a future that may hold even more unpleasant surprises. Are they ready? Disease Management Consolidation There is a trend among disease management vendors to … Read more

Article also available in PDF As managed care becomes the norm in many parts of the nation for the commercial population, Medicare and Medicaid are increasingly seen by health plans as areas of growth. According to data from the Health Care Financing Administration, Medicare risk plan enrollment has grown an average of 21 percent a … Read more

The disease management industry worries about a bill sent to California’s governor that would allow medical information to be shared only when a physician authorizes DM services…. The American Osteopathic Association won’t follow the AMA’s lead. It voted not to form a doctor union…. In Washington, where insurers have been dropping individual policies, only one … Read more

By MargaretAnn Cross As Marriott International works to renew contracts with HMOs for next year, it is requesting that health plans agree to specific clinical targets. The Washington, D.C.-based hotel chain is working with 80 HMOs to set appropriate goals for child immunization rates, prenatal care, mammography screenings, and more. “We want to make sure … Read more

People Today Need Advantage, whether that Is out of their Mechanic, merchant or provider. NRC Health’s Economy Insights researched more than 223,000 healthcare users and found that 51 percent said access and convenience to care would be the most crucial facets within their own decision-making. That is preceding insurance plan, doctor/nurse behavior, brand standing and … Read more

Whatsoever the 109th Congress soweth, so shall the 110th Congress reap. Just before adjourning last month, the outgoing Congress passed legislation that would set up a pay-for-performance program in Medicare. The reviews, by critics who can wield votes as well as opinions, have been mixed, and there is already doubt about the law surviving in … Read more

The appropriate cliché at the appropriate moment can have an impact. For instance, hearing “the right hand doesn’t know what the left hand is doing” in a hospital might be enough to spin you right back out the revolving door. You know the horror stories. Wrong limb amputated. Forgotten utensils cozying up to innards for … Read more

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

Officials at Molina Healthcare closed its online portal for claims information last Friday, fearing a breach of cybersecurity that may have exposed the medical information of some of its 4.8 million members, Kaiser Health News Reports. The company operates in 12 states and Puerto Rico. The company said in a statement: “We are in the … Read more

By Thomas J. Garvey, M.H.A. If you put a frog in boiling water, it will attempt to escape for self-preservation. But if you take the same frog, place it in lukewarm water, place that water over a stove and gradually turn up the heat, the frog’s system will adjust to the change and eventually the … Read more

They’re still concerned with individual patients, but they’ve also been enlisted to provide care to populations. More hospitals are utilizing hospitalists in a variety of ways in an effort to improve outcomes. The percentage of hospitals using hospitalists has risen dramatically over the past dozen years, from just 29% in 2003 to 50% in 2007 … Read more

This really is the 2nd most popular treatment for patients having such a mutation. Approximately 8 percent of patients with DMD possess a mutation that’s amenable to exon 5-3 skipping. “The FDA is devoted to boosting medication development for acute neurological ailments such as Duchenne muscle dystrophy,” explained Billy Dunn, M.D., manager of work of … Read more

Back from obscurity, the Patients’ Bill of Rights is poised to become an issue in the presidential election — depending on whom you ask. Michael Chiusano “It’s time for our nation to come together and do what’s right for the people. I support a national Patients’ Bill of Rights…” said candidate George W. Bush at … Read more

Results from pay-for-performance (P4P) programs are spotty and few plans have set up adequate tracking methods, according to Hindy Shaman, a director in the health industries group at PricewaterhouseCoopers. How would she grade these programs? “It has been mixed as far as the level of resources commercial plans have put in, the level of financial … Read more

Overall drug costs are likely to increase over the next couple of decades because of the size of the aging baby boom generation in relation to the total population. That statistic is even more sobering when you realize that the proportion of Americans diagnosed with Alzheimer’s disease is projected to nearly triple. In fact, the … Read more

Sildenafil citrate has been the first oral medication approved for treating erectile dysfunction, that is often found in men who have cardiovascular illness. ED is defined as the inability to accomplish and manage an erection adequate for satisfactory intercourse. The incidence of medium to entire ED was reported to function as 30% in men aged … Read more

MANAGED CARE August 2009. ©MediMedia USA The job market looks rosy for pharmacists: The U.S. Department of Labor expects employment of pharmacists to increase much faster than the national average of all occupations through 2016. Specifically, employment of pharmacists is expected to grow by 22 percent between 2006 and 2016. The increasing number of middle-aged and elderly … Read more

Sharpless is heading back to NCI Stephen Hahn, MD, the chief medical officer of MD Anderson Cancer Center in Houston, was nominated today by President Trump to be the next FDA commissioner, according to multiple media reports. The acting FDA commissioner, Norman “Ned” Sharpless, MD, is returning immediately to his previous job as NCI director. … Read more

The business plans to initiate a Stage 1b/Phase two trial in patients with systemic sclerosis-associated bronchial lung disorder at 2021. “We are excited that ACE-1334 has received Orphan Drug designation, since it contrasts with your vision to create novel treatments for psychiatric diseases of high unmet clinical necessity,” stated Habib Dable, President and ceo of … Read more

Managed care organizations, concerned that the malpractice-insurance upheaval will thin provider panels and create access difficulties, are watching tort-reform efforts closely. Are we merely seeing the underwriting cycle at work? John Carroll When Mississippi Gov. Ronnie Musgrove called a special session of the legislature last September, a majority of lawmakers arrived in Jackson ready to … Read more

Healthcare IT costs in 2015 Climbed to More than 32,500 per Fulltime. The 20-16 Revenue and Cost Report Is a good benchmarking tool for the health business, and it has been since it was published in ’09. Certainly one of those Main aspects which raised IT costs on the previous 6 years has been the … Read more

Humana hopes to gain a competitive edge by joining two important components of today’s insurance — consumer-directed health plans and information technology — with a rare cap on premium hikes. The health plan launched SmartAssurance on June 2, capping rate increases at 9.9 percent in the second year for customers enrolled in SmartSuite, a consumer-directed … Read more

Drug Cost-Sharing Amounts Stable 2010 to 2011 Submitted by webadmin on Wed, 2012-02-08 07:28 From Managed Care The vast majority of Part D plans follow a tiered cost-sharing structure with incentives for members to use less expensive generic and preferred brand-name drugs. Cost-sharing has increased since 2006, but the Kaiser Family Foundation reports in “Analysis of … Read more

Based on a satellite symposium at SLEEP 2006 — the 20th anniversary meeting of the Associated Professional Sleep Societies, this supplement reviews past and present sleep management practices and identifies and addresses barriers to suitable care. The authors examines the impact of sleep disorders on patients, providers, and employers. Highlights: The Economic Burden of Chronic … Read more

Experts at three PBMs say watch out for several recently approved and expected-to-be-approved medications Specialty medications will continue to dominate the pharmacy benefits landscape next year. “Several new breakthrough drugs — incredible medications for patients — have received recent approval and more are anticipated in 2015,” says Sharon Frazee, vice president for research and analytics … Read more

Adjusted for inflation, physicians’ net income from the practice of medicine declined 7 percent between 1995 and 2003, according to a national study reported by the Center for Studying Health System Change. Primary care physicians and general surgeons fared the worst in keeping pace with inflation; specialty occupations did much better. The study cites flat … Read more

We have all heard those ominous numbers forecasting that half of all drug costs will be from specialty products in the near future. As is evident from the graph below, the future is not far off because, according to Avalere, adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) were among the 10 drugs with highest revenue … Read more

Primary care physicians enjoyed a 4 percent increase in compensation in 2006, less than the aggregate of medical and surgical specialties, which had a 6 percent increase, according to the American Medical Group Association. But if you look at the graph below, you’ll see that over the three years ending in 2006, primary care specialties … Read more

The portfolio, also approved for conditional used within an magnetic resonance imaging surroundings, so ” consists of a family group of non invasive, rechargeable and non-rechargeable, implantable pulse generators that power Cartesia™ Directional Leads, made to supply best symptom relief. More than 10 million individuals globally are living with Parkinson’s Disorder — a progressive, neurodegenerative … Read more

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

Although the rate of increase in HMO profits was much less in 2004 than in 2003, plans continued to see good earnings, according to a study by Weiss Ratings. Overall, the HMOs’ profits increased 10.7 percent in 2004, according to data collected from 515 managed care organizations. Weiss points out that this follows a very … Read more

Democratic state Rep. Patricia Gray has introduced legislation to make Texas the fifth state to assure women direct access to Ob/Gyns and the right to designate Ob/Gyns as their primary care physicians.Gray, who represents part of Galveston County, objects to gatekeeper policies that require women to see family doctors or internists before they can visit … Read more

As we were going to press, huge managed care merger news broke. Anthem plans to purchase WellPoint for $16.4 billion, thereby creating the largest health insurer in the nation. This is the exclamation point to a story long tracked here and elsewhere: the continuing merger of plans that are part of the Blue Cross and … Read more

Training primary care physicians to identify and treat oral health problems will go a long way toward integrating care for those problems with general medical care, according to a study in the Journal of the American Board of Family Medicine. “The historic separation of oral health care from the broader health care delivery system has fostered … Read more

States are liberalizing their marijuana laws. Federal officials may be ready to take a step in that direction by ending the restrictions on a key ingredient, cannabidiol. The credibility of cannabis as a source of a legitimate pharmaceutical ingredient in prescription medications took a major step forward in 2018 when the FDA approved Epidiolex (cannabidiol) … Read more

“This approval marks a fresh type of anti retroviral medications which could benefit patients that have conducted out of HIV treatment alternatives,” stated Jeff Murray, M.D., deputy manager of the Department of anti-virals at the FDA’s Center for Drug Research and Evaluation. “The access to new types of anti retroviral medication is essential for heavily … Read more

MANAGED CARE June 2006. ©MediMedia USA In this age of consumer-directed health plans, it’s heartening to see a study that says that employers believe their workers can learn what they need to know to become better buyers of services. It is less reassuring to find in the same study that only about 25 percent of the 1,675 … Read more

The Center for Medicare & Medicaid Services is a rich source of price and quality data. Isn’t it about time it shared that data? Nancy E. Taylor William B. Eck “You can become an informed consumer before you purchase your automobile …. that same sense of transparency and information ought to be available in health … Read more

Whether biosimilars can turn the tide of rising pharmaceutical expenditures is yet to be seen, but MANAGED CARE readers are optimistic about their chances. In an online survey of readers conducted in late January and early February, 20% of the 113 respondents indicated that they believe that biosimilars will be highly effective in lowering drug … Read more

To meet this goal, recommendations in prevention, identification, and treatment have to be implemented extensively into the US populace. That public is currently described by an amazingly shifting demographic profile. In the previous few years, the US populace has become more ethnically diverse as it was. The existing representation of non-Hispanic whites in this country … Read more

The Joint Commission on Accreditation of Healthcare Organizations and the Commission on Accreditation of Rehabilitation Facilities have struck an agreement intended to eliminate duplicate surveys of freestanding medical rehabilitation hospitals and rehab units in acute care hospitals. Initially, JCAHO will recognize CARF accreditation of rehab hospitals seeking Joint Commission accreditation. After Aug. 1, recognition will … Read more

Higher overhead is stifling the growth of physician salaries, say the authors of a new study of physician compensation. From 1996 to 1997, median compensation for all primary care physicians rose a mere 0.42 percent, even lower than the previous year’s growth of 1.42 percent. According to Cejka & Co., a St. Louis health care … Read more

Newt Gingrich HEALTH PLAN 2009 Former Speaker of the House Newt Gingrich is the founder of the Center for Health Transformation (www.healthtransformation.net) and the author of Saving Lives & Saving Money. The dominant model of the 21st century will be more choices with better quality at lower cost. This is already true in nearly every segment … Read more

That coronation of value-based care that everybody is talking about—it may need to be delayed, judging by the results of a physician survey by Deloitte earlier this year. Deloitte’s “2016 Survey of U.S. Physicians” asked 600 primary care and specialty physicians how far along they are in transitioning from a volume- to a value-based system … Read more

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

Preauthorization procedures for costly new imaging technologies aim to help doctors learn the rules to avoid denials Medical directors take note: Radiology benefit managers are implementing new procedures to streamline the approval process and tackle the complex and diverse factors that encourage use of these expensive tests. This means that they are trying to improve … Read more

Treatment comes up short against chemotherapy regimens Bristol-Myers Squibb has announced that its CheckMate-026 trial, a phase 3 study investigating the use of nivolumab (Opdivo) as monotherapy, did not meet its primary endpoint of progression-free survival (PFS) in patients with previously untreated advanced non–small-cell lung cancer (NSCLC) whose tumors expressed programmed death ligand-1 (PD-L1) at greater … Read more

Steven Peskin, MD This post is not about coronary artery disease. Nor is it about the “stiff” ventricles in diastolic heart failure. Like “Never Rest”, which I posted several weeks ago, this brief discussion was inspired by Saturday morning Torah study. “Harden Heart” refers to the Pharaoh at the time of Moses and the Exodus … Read more

MANAGED CARE September 1999. ©1999 MediMedia USA Humana says it will take six months to name a new CEO, following Gregory Wolf’s resignation last month to pursue those always-mysterious other interests. Retired CEO and chairman David Jones is back until a successor can be found. The company wouldn’t say what prompted the abrupt end to Wolf’s 20-month … Read more

Competitors are coming together to see if they can leverage blockchain’s magic to solve big problems. Provider directories are among the first use cases. Mike Jacobs works in technology engineering at Optum, UnitedHealth Group’s technology and health care services unit. Kyle Culver has a similar job at Humana. UnitedHealth and Humana are competitors, but now … Read more

The push to mandate this electronic tool is increasing in intensity, but dealing with costs and coming up with standards remain obstacles Electronic prescribing is the holy grail of medication safety. “Its two-fold potential is very significant,” says J. Lyle Bootman, PhD, dean of the College of Pharmacy at the University of Arizona–Tucson, and a … Read more

Princeton University economist Uwe Reinhardt, PhD, says that American businesses have the habit of reinventing old institutions and giving them new names. “The famed Massachusetts Connector was once known as Health Insurance Purchasing Cooperatives (HPICs), then Health Alliances by the Clintons, then something else again by Republicans, and so on. Always the same,” says Reinhardt. … Read more

MANAGED CARE February 2008. ©MediMedia USA Regence’s effort gets nod of approval from physician organization because it allows providers to respond Frank Diamond “Without feedback it’s really hard to improve and most doctors want to be the very best they can,” says Jeff Robertson, MD, the executive medical director at Regence. Here’s what it’s not about: It’s … Read more

MANAGED CARE January 2005. © MediMedia USA Health Plans Slow To Adopt Outpatient Prospective Payment The private sector drags its feet over Ambulatory Payment Classifications. Here are some suggestions to move acceptance along. Renee Leary, MPH Dean Farley, PhD When Medicare implemented its APC-based (Ambulatory Payment Classifications) hospital outpatient prospective payment system (OPPS) four years … Read more

On the whole, large employers are more satisfied with their pharmacy benefit managers than are HMOs, but a study released by the Pharmacy Benefit Management Institute suggests that both groups find their PBMs lacking in some aspects of utilization management and service. Room for improvement Employers and HMOs share common concerns about their PBMs. Figures … Read more

How well physicians fit in with the corporate culture of provider organizations such as hospitals and group practices influences whether they’ll stay or even whether they’ll come aboard in the first place, according to a study by Cejka Search and Physician Wellness Services, a company that tries to help provider organizations run more smoothly. “When … Read more

COVER STORY Missing the Mark Health plans that miss the mark are out there, but trying to identify them is akin to the plight of the X-Files agents who find circular traps at every turn. This package also examines: * Characteristics of plans that miss the mark * What to do if your health plan … Read more

Follow this link to PDF version COMPENSATION MONITOR For the first time in two years, average cash compensation edged up slightly in 1999 for physicians whose patient bases were more than half managed care, while for the first time since 1994, compensation dropped when more than half of patients were under fee-for-service coverage. Meanwhile, the … Read more

Young women on Medicaid tend to skip physicals because of child care concerns. One insurer thinks it might have an answer. Twice as many Medicaid beneficiaries report barriers to getting primary care as do people with private insurance, according to a new study. They’re also twice as likely to visit emergency departments. This situation seems … Read more

“Market of food will be patriotism,” in accordance with a global War I-era U.S. Government poster. “Waste of food is more disloyalty,” it includes, as foods–notably meat, wheat, fats and sugar –were mandatory by American troops and the taxpayers of war torn Allied states.1 From the following 85 decades, American attitudes shifted appreciably. Focus of … Read more

Success is relative. Health care costs may have actually decreased year to year during the Great Depression, when deflation was the scourge for a time, but since our records don’t go back that far, it is impossible to say for certain. This year, the rate of increase has slowed, according Segal, the consulting company. That’s … Read more

If it weren’t for the recent passage of the Patient Protection and Affordable Care Act (PPACA), there would have been very little progress made toward reducing the overall number and the percentage of uninsured adults in the United States. Efforts to expand children’s coverage is another matter. Census Bureau statistics bear this out: The portion … Read more

Pharmacy issues may greatly affect members’ perceptions of their health plans, suggests a survey of 38,000 enrollees who requested prescriptions for specific drugs. Denied what they wanted, these members were twice as likely to want to leave their health plans as were those who got the drug they requested. The percentage of members who rated … Read more

The U.S. pharmaceutical market was $211 billion in 2003, the first time the market exceeded $200 billion. Roughly $22 billion of that market was biotech products, according to IMS Health. The strongest growth was seen in the generic and biologic sectors. Managed care plans and pharmacy benefit managers can benefit from the strong generic presence … Read more

THE FORMULARY FILES Zetia study keeps PCSK9s on approval course Pharmacy directors at health plans can feel free to include ezetimibe (Zetia), the nonstatin lipid lowering medication, on their formularies thanks to results of a clinical trial unveiled by the American Heart Association. The trial looked at the effects of ezetimibe over seven years. Researchers … Read more

Advances in biologic and small molecule medicine result in two different types of treatments that target the same cell receptor There are dramatic differences between biologic drugs and small molecules. Biologically-derived drugs require manipulation of an organism’s genetic code. The organism, a bacterium, yeast cell, or mammalian cell, then creates the protein. A manufacturer seeks … Read more

With the exception of specialty drugs, enrollees in Medicare Part D plans paid more for their commonly used drugs than beneficiaries in employer plans, according to a recent report, “Medicare Prescription Drug Plans in 2008 and Key Changes Since 2006: Summary of Findings.” Although there has been minimal change in coverage benefits among Part D … Read more

Value-based benefit design could go a long way in managing chronic conditions. Most employers have ignored this option so far. Thomas Reinke Consumer-directed health plans (CDHPs) have moved out of the shadows of PPO and HMO plans and into the forefront of employer strategies for health care benefits. “Large employers are offering CDHPs or, in … Read more

Use of financial incentives in HMOs’ contracts with physicians may be losing favor, but it’s not about to be declared outright illegal any time soon. The U.S. Supreme Court ruled unanimously that patients maynot sue a health plan just because it offers physicians incentives intended to limit health care services. Cynthia Herdrich of Bloomington, Ill., … Read more

Clinicians can consider this radiotherapy a viable treatment option Thomas Morrow, MD There are about 25 million people in the United States who have asthma, whose hallmarks are hyper-responsive airway constriction of the smooth muscle, increased mucus production, and inflammation of the airways. This results in shortness of breath and significantly diminished quality of life. … Read more

A health plan’s systematic approach to dealing with common chronic illnesses is on the edge of remarkable outcomes. Physician buy-in can be slow, but is crucial. The challenge many health plans and integrated health systems face — transforming the delivery of care into a systematic approach that is based on the best medical evidence — … Read more

Multiple formulary controls are becoming more prevalent among HMOs as managed care organizations and purchasers look for ways to keep pharmacy expenses within budgets. Formulary control trends suggest that the uses of therapeutic interchange and variable copayments are HMOs’ fastest-growing cost-control strategies. Color chart

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

Approval decision set for September The FDA has announced that the new drug application for Remoxy (Durect Corporation/Pain Therapeutics), an abuse-deterrent formulation of extended-release oxycodone (CII) capsules, is sufficiently complete to permit a substantive review. September 25, 2016, is the target action date under the Prescription Drug User Fee Act (PDUFA). Remoxy, an investigational drug, … Read more

The percentage of Americans under age 65 with employer-sponsored health coverage grew slightly from 63.5 in 1993 to 64.9 in 1998, following five years of erosion. A report by the Employee Benefit Research Institute attributes the gain to a smaller pool of self-employed workers and an increase in the number of people working for large … Read more

The Prestige Cervical Disc system can replace a single disc from C3 to C7 and gives people with cervical disc disease another viable treatment option Thomas Morrow, MD In July, the FDA approved the marketing of the Prestige Cervical Disc made by Medtronic Sofamor Danek of Memphis. This is the first artificial cervical disc approved … Read more

The American Nurses Association (ANA), through its 54 constituent member institutions say and territorial nurses associations along with also the Federal Nurses Association, may be the sole full-time professional firm representing the interests of their state’s 2.7 million registered nurses. In accordance with the ANA’s website, that the”ANA advances the nursing profession by fostering high … Read more

HMOs are not rushing to follow the lead of the largest not-for-profit health plan because they fail to see how this makes them more competitive. Kaiser Permanente’s recent mandate to post clinical treatment guidelines on its web site for enrollees later this year produced a ho-hum response from major health plans. Consumer groups hoped Kaiser’s … Read more

Seema Verma, a longtime advisor to Vice president Elect Mike Pence, has been nominated by President-elect Donald trump to head the Centers for Medicare and Medicaid Services. CMS oversees Medicare, Medicaid and some aspects of the ACA, affecting the lives of some 100 million Americans. Verma, 46, is CEO and founder of SVC, a national … Read more

Resources Disease Management Forum Call for Manuscripts Subscribe Rate Card Production Details for Ads and Inserts Classifieds Recent blog posts Super-Utilizers versus Non-Utilizers Disruptive Innovation Could Up-End an Innovative Industry Is There an Advocate in the House? Health Reform and the Use of Financial Incentives in Wellness Programs An Easy and Profitable Way to Turbocharge … Read more

In the first of several posts, Tom Ewers and Munzoor Shaikh of West Monroe Partners discuss the dynamics of health care payer mergers. Here, they describe how success hinges on several key ingredients in the stages before closing — the pre-close stage. For health care payers, pre-close homework is the most critical factor leading to … Read more

HMOs and, to a lesser extent, employers that contract with pharmacy benefit management companies were happier last year than they were the year before with the PBMs’ performance, the Pharmacy Benefit Management Institute found in a poll. PBMI received responses from 330 large employers (more than 2,500 employees each) covering more than 10.5 million people, … Read more

The doctor-patient relationship is the foundation of modern medical ethics. It is the touchstone for our professional conduct and the single matter that physicians, when polled, say we value most about medical practice. But the doctor-patient relationship is changing, and so is medical ethics. To maintain the values that doctors and patients appreciate most, the … Read more

Symptom relief was the only treatment for hemoglobin found in the urine. Now Solaris prevents the complement cascade. Thomas Morrow, MD Paroxysmal nocturnal hemoglobinuria (PNH) is caused by a biochemical blood cell defect that arises from an acquired genetic mutation in the stem cell lines in the bone marrow. For unknown reasons, the abnormal cell … Read more

Prescription Medication, sometimes, are mandatory, while used to fight an ongoing disease or cure a chronic illness. Though generic medication are more cheap for the majority of the people, brandname drugs frequently cost markedly longer. Americans spend roughly $1,200 On prescribed medication each year, a number which has grown fast over the last ten years. … Read more

Employers know that managing chronic conditions and preventing drug-drug interactions can boost productivity There’s no denying that the medication therapy management programs (MTMPs) mandated for Medicare Part D plans have been beneficial for seniors, producing positive results that help seniors live healthier lives. The basic principles of these programs are transferable to commercial populations, providing … Read more

Payers and buyers are searching to comprehend how VBID fits in to how services have been chosen and paid for, so optimizing the maintenance given to your cash spent. Use the exact same anticipation for your own healthcare spending, nevertheless, and you may place your self up for disappointment. “Rather than concentrating on cutting edge … Read more

Authority, a thirdparty product certificate body, says will proceed to prohibit delta-8 THC along with other services and products like it as the cannabinoid can be a intoxicant termed a regulated substance under federal lawenforcement. “Don’t sell or produce delta-8 services and products with no license to sell or produce THC as being a regulated … Read more

Leaving the gym on an unseasonably warm night, I struck up a conversation in the parking lot with a vascular surgeon acquaintance. He recounted a technically demanding procedure that he had done the day before with a reported 10 percent risk of stroke and a 3 percent mortality risk. The two-stage procedure was optimally done … Read more

Rates of use for three advanced imaging modalities — magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) scans — increased rapidly between 2000 and 2004. Jean M. Mitchell, PhD, professor of public policy at Georgetown University, examined claims data for physician and outpatient services for people with health insurance coverage from … Read more

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

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

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

LOOKING FORWARD For other articles in the series, see listing at end Steve Wetzell Buyers of health care are looking at risk adjustment to discourage parsimonious care. They’re also hoping to transfer power and responsibility to workers. Historically, businesses that provide health coverage have acted independently, doing their best to balance the pressure points: network … Read more

California sets a precedent again, with a bold effort to regulate the HMO industry. While the new Department of Managed Health Care is facing down 50,000 consumer gripes monthly, director Daniel Zingale intends to keep administrative red tape from overwhelming plans, patients, providers, and his department. Sniping at HMOs seems to be a national pastime, … Read more

No sooner had the quality rankings of health plans in the nation, as measured by the National Committee for Quality Assurance (in partnership with U.S. News & World Report), been released then it was pointed out that most of the top performers werenot-for-profit insurers. Of course, making that argument was the lobbying group, the Alliance … Read more

Gauging and rewarding good work in health care is a noble goal with potentially negative consequences Martin Sipkoff The good inherent in evidence-based medicine — the cornerstone of quality measurement — can be compromised by the complexity of processes used to achieve its implementation. If transparency is confused with accountability and incentive programs are perceived … Read more

Sticks, as well as carrots, are used in some commercial and government programs to encourage beneficiaries not to undermine their health Virtually every company health plan sold includes at least a few members that tilt the scales of risk to the danger zone. Anyone who is obese or smokes is an automatic member of the … Read more

Anyone who spends much time talking with me knows that one of my concerns, and not just as an editor, is the misuse of language by people in health care. Yes, I have a list of examples, and I might share that in a future essay. Today, we’ll consider just one problem. You’ll be hearing … Read more

Dissatisfied customers have a tendency to lash out and not be very discriminating about their targets. Prescription: Reduce the hassle. Senior Vice President, Managing Director Managed Markets Torre Lazur-McCann Healthcare WorldWide Recommended: PDF version, includes seven charts You think patient satisfaction with the health system is marginal in the doctor’s office after a decade of … Read more

VIEWPOINT SNFs Need Real-Time Data To Succees CMS has been pushing acute providers to connect the continuum for several years. Now that multiple CMS programs include claims-based measures that track patients outside of skilled nursing facilities—the Value-Based Purchasing, SNF QRP (Quality Reporting Program), and Five-Star programs—it’s clear that post-acute providers are expected to start monitoring … Read more

It’s a costly time for hospitals. In the report, “Trends in Hospital Inpatient Drug Costs: Issues and Challenges,” the National Opinion Research Center found that inpatient drug costs per admission are skyrocketing, having increased 38.7 percent in the three-year period from 2014 to 2016. These increases are due to higher demand for prescription drugs and the … 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 chairman of Rx.com has suggested a third form for prescription reimbursement: Internet Retail Pharmacy, or IRP. Joe Rosson says such a category would save money for health plans, pharmacy benefit managers, and self-funded employers, which reimburse online drug sellers on the same basis as retail pharmacies. Third-party payers negotiate separate rates for retail and … Read more

Consensus seems to be building over a Senate bill that is acceptable to some health plans and employers For years now, advocates of a mental health parity law have had the votes they needed in Congress to pass a bill. However, every year until now, Republican House leaders quietly shoved it aside, making sure it … Read more

Women’s groups are lobbying Congress to require coverage of female prescription contraceptives now that more and more insurance companies say they are willing to pay for at least a few doses per month of the male impotence pill Viagra. According to one group, it’s unfair for insurers to help men have more and better sex, … Read more

Rehabilitation at a skilled nursing facility lacks the intensity that most patients need, studies suggest For 750,000 people who suffer a stroke each year in the United States, quality physical medicine and rehabilitation are among the most critical components in overall management of those with residual disability. Everyone agrees that in post-stroke care, the goal … Read more

Sometimes even wonderful news comes with caveats. Deaths from cancer fell for the second straight year, the American Cancer Society reports. There was a drop of 3,014 cancer deaths from 2003 to 2004, the most recent year for which information is available. This was “no fluke,” says John R. Seffrin, the society’s chief executive officer. … Read more

Hindsight is 20/20, but was this predictable? After a year and a half of hard work, a blue-ribbon commission that set out to keep Medicare from running into a ditch itself slid off the road, thanks to deep ideological divisions regarding government’s role in health care. The commmission disbanded without a recommendation — consigning the … Read more

The title is part of a quotation from Henry Chao, a CMS official who is involved with building and launching the health care exchanges. The federal government is running or co-managing 33 exchanges. They are expected to be functional by October 1 to enroll patients for coverage starting on January 1. At a recent panel … Read more

Paying attention to how elements of the system mingle is crucial for improving quality, says the man who spearheaded the latest Institute of Medicine study. See an accompanying article “IOM Notes Shift to Chronic Care Management” Since America’s $1.4 trillion health care “system” is hardly systematic, an important question to ask when trying to improve the … Read more

What Does not get just as much care would be healthcare worker safety, unless it’s from the circumstance of front burner problems just like the H1N1 flu pandemic, or even the spate of unrelated and recent assaults in boston-area healthcare centers. The simple fact is that working in a clinic can be toxic to your … Read more

Realtime Continuous glucose monitoring is the newest technological breakthrough in cardiovascular care. Despite its own limits of lag period between blood and sensor sugar, the demand for calibration, fictitious detection of failure to detect dimmed, and mild discomfort or skin irritation recorded in certain users, RT-CGM is still an extremely beneficial tool which may be … Read more

Physician practice managers are in a central position because they interact with health plans that determine quality targets and financial incentives, such as pay-for-performance programs, and with the physicians and other providers in their organizations. A study published in Medical Care Research and Review bears this out. Researchers interviewed practice managers about how financial incentives … Read more

Restrictions blunted the effect of Sovaldi and other antivirals on Medicaid budgets. The gradual removal of these barriers is going too slowly, say advocates. More than four years ago, CMS warned state Medicaid programs that they may be violating federal law by restricting access to antiviral hepatitis C drugs such as Sovaldi (sofosbuvir) and Harvoni … Read more

Washington Watch Medicare reform — and especially prescription drug benefits within Medicare — no longer appears to be the burning issue it once was on Capitol Hill. The culprits: priorities and money. “It’s looking like the price may be too high, and I think there’s no sense of urgency about it right now,” one Capitol … Read more

The National Committee for Quality Assurance’s plan to bring the disease management industry under its accrediting umbrella seems to be off to a running start. The NCQA announced Dec. 4 that 18 organizations have already agreed to participate in its Disease Management Accreditation and Certification program. Under the proposal, which was scheduled to be launched … Read more

Small and mid-sized employers (10-999 workers) saw average health-benefit-premium increases of 9.2 percent last year. Marsh Inc. reports that these companies aggressively blunted the effects of fast-rising health care costs, using out-of-pocket cost-sharing options — such as replacing copayments for prescription-drug coverage with coinsurance — and by moving away from open-access-style plans and back to … Read more

About 15 million new enrollees are expected to flood Medicaid in 2014, a massive 30 percent increase. Health plans have been preparing for some time, because states, already burdened by the program, are looking to managed care to help control costs. (http://bit.ly/gPqf95) Provider data management will be crucial to making managed Medicaid work, says Michael … Read more

Tennessee Gov. Don Sundquist has proposed a radical overhaul of the state’s managed Medicaid program. TennCare was close to collapse after some participating health plans experienced financial problems or threatened to pull out. Sundquist’s plan would boost premiums and transfer some risk to the state. Until now, health plans have borne all risk, and they … Read more

Hospitals have opportunities to reduce the use of expensive or hard-to-get drugs and save money without compromising patient care, according to Andrew Donnelly, director of pharmacy services at the University of Illinois Hospital and Health Science System (UI Health), who spoke at a meeting of the American Association for the Advancement of Science in Boston. … Read more

Fighting Invisible Barriers To Equitable Health Care Unintentional bias can be just as damaging as the overt brand, according to the president of the National Medical Association. Last August, Rodney G. Hood, M.D., was installed as the 101st president of the National Medical Association, which represents more than 25,000 African-American physicians. As president, he will … Read more

One percent of patients undergoing immunotherapy for cancer develop type 1 diabetes, what Mario Sznol, MD, an oncologist at Yale School of Medicine, described in Stat as an “unfortunate trade-off.” Sznol is treating Rich Lenihan with checkpoint inhibitors for Lenihan’s skin cancer. Jamie Vidal, who is not one of Sznol’s patients but whose diabetes also resulted from … Read more

Legislators are being urged to reward companies that provide programs for their workers, but success has been mixed MANAGED CARE February 2008. ©MediMedia USA Wellness Legislators are being urged to reward companies that provide programs for their workers, but success has been mixed Michael Levin-Epstein When it comes to encouraging wellness programs, government is starting … Read more

Unintentional bias can be just as damaging as the overt brand, according to the president of the National Medical Association. Last August, Rodney G. Hood, M.D., was installed as the 101st president of the National Medical Association, which represents more than 25,000 African-American physicians. As president, he will focus on eliminating racial and ethnic health … Read more

Sharon Carter Many doctors think the only thing more difficult than dealing with patients is supervising employees. They didn’t offer Management 101 in medical school. Here are some simple approaches that may make life easier. MANAGED CARE March 1998. ©1998 Stezzi Communications Many doctors think the only thing more difficult than dealing with patients is supervising employees. … Read more

A Conversation With Robert Wachter, MD: Medicine’s Bumpy Ride Into the Digital Age Departments Medication Management Spending on Compounded Drugs Goes Sky High Soaring prices and aggressive marketing fuel a buying frenzy for these specially made agents. The industry says it is meeting a need. Snapshot Medicaid expansion linked to diabetes diagnosis News & Commentary … Read more

Initial results are promising. Employees turn toward preventive medicine and away from expensive drug therapies. Health care insurance can be worth as much as hourly wages for some employees at Hannaford Brothers, a Scarborough, Maine-based supermarket chain. That means they have to be happy with it, says Peter Hayes, Hannaford’s benefit strategist. “If we’re spending … Read more

Just What Causes Health Care Inflation?   Aging of the population and increased demand for services are not why costs have risen so quickly in health care, according to a study in the Journal of the American Medical Association. “Between 2000 and 2011, increase in price (particularly of drugs, medical devices, and hospital care), not … Read more

Name Last modified Size Description Parent Directory 28-Aug-2000 11:10 – ../../../../archiveMC/9711/9711.addyears_large.gif 17-May-2000 12:17 17k ../../../../archiveMC/9711/9711.addyears_small.gif 17-May-2000 12:17 11k 9711.amap.shtml 17-May-2000 12:17 8k 9711.capitation_part..> 17-May-2000 12:17 19k 9711.capitation_part..> 17-May-2000 12:18 17k 9711.capitation_part..> 17-May-2000 12:18 8k 9711.compass.map.gif 17-May-2000 12:18 15k 9711.compass.nationa..> 17-May-2000 12:18 15k ../../../../archiveMC/9711/9711.compass.pdf 17-May-2000 12:19 155k 9711.compass.regions..> 17-May-2000 12:19 28k 9711.compass.reportc..> 17-May-2000 12:19 30k 9711.compass.shtml … Read more

When Massachusetts State Senator Mark Montigny (D–New Bedford) read about a prince who received special treatment at a Boston hospital, he got hot under the collar. Montigny convinced his colleagues to back a budget amendment to fine hospitals for giving special status to wealthy patients, and the state Senate unanimously passed the measure, according to … Read more

Prescription drug shortages worsened last year, shooting up to 267, according to the University of Utah Drug Information Service. In 2010 there were 211 drug shortages. Such shortages can be frustrating for health plans. Clinicians complain that the gray market, where pharmaceuticals can be repriced, is becoming unmanageable. Fewer than half of respondents in a … Read more

Byvalson (nebivolol/valsartan, Allergan) 5 mg/80 mg tablets have won FDA approval for the treatment of patients with hypertension to lower blood pressure. Byvalson is the first fixed-dose combination (FDC) of a beta blocker (BB) and an angiotensin II receptor blocker (ARB) available in the United States. The FDA’s decision was based on positive data from … Read more

Compared to women from Additional Highincome States — for Example, for America spends more on medical care compared to many other states do, however, Americans report elevated levels of perhaps not needing attention due to costs, in addition to high cases of chronic illness. Ahead research has discovered that poor accessibility to primary care within … Read more

Aimovig and other drugs targeting the CGRP neuropeptide aim to prevent migraines in a whole new way. But Aimovig’s cost may mean an obstacle course of prior authorization and step therapy. In May the FDA approved a novel medication, Aimovig (erenumab-aooe), codeveloped by Amgen and Novartis, for the prevention of migraines. It’s novel in the … Read more

Not surprisingly, the House of Representatives’ 275–161 vote affirming the Norwood-Dingell health care reform bill prompted wailing and gnashing of teeth from the insurance industry. A Health Insurance Association of America study tallied 408 new mandates in the bill — more than double that proposed in Norwood’s 1998 legislation, PARCA. The American Association of Health … 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. Cyril F. Chang, PhD Methodist LeBonheur Center for Healthcare Economics, Fogelman College of Business and Economics, University of Memphis Full text in PDF TennCare is one of the most … Read more

A national leader in physician quality improvement believes providers should be judged on the services they provide MANAGED CARE April 2008. ©MediMedia USA A national leader in physician quality improvement believes providers should be judged on the services they provide Performance over pedigree is how Bruce Bagley, MD, the medical director for quality improvement, would like to … Read more

The U.S. Food and Drug Administration chose to not accept Translarna (ataluren), by PTC Therapeutics, being cure for certain kinds of Duchenne muscle dystrophy due to”crap” mutations. This opinion has been supported by 10 of their panel 11 associates and steered with an FDA briefing record supplied to the advisory panel ahead of their meeting. … Read more

Monoclonal antibody promotes blood coagulation Four patients have experienced serious thrombotic events in a clinical trial of the experimental hemophilia medication emicizumab (ACE910, Genentech/Roche), dimming hopes for the potential blockbuster drug, according to a Reuters report. The patients were being treated for breakthrough bleeding. A Roche spokesman told Reuters that the cases involved patients who … Read more

Last year it was Sovaldi. This year it has been the PCSK9 inhibitors, Daraprim, and the tangled (and unsavory) relationship of Valeant and Philidor. Who can say which drugs or what companies are going to leap into headlines and stir up Internet buzz in 2016? But there’s no question that the high price of pharmaceuticals … Read more

Approval of Merck’s Check Point inhibitor is further Signs that cancer Treatment choices are becoming more and more determined by the PDL1 biomarker As well as other molecular-level gaps in cyst cells. But studying for PDL1 is catchy, and variants from the concentration of PDL1 cells in Various areas of the sample may create different … Read more

From Pharmacist to Manager, With Many Hurdles Along the Way Dealing with that most volatile chemical mix, human beings, means being challenged every day Satisfying the P&T Committee’s Need for More Evidence Health plans seek drug review summaries from other plans, vendors, and online sources The Logjam Went Data Way In Pittsburgh, new interconnectivity between … Read more

More Will Be Expected of Pharmacists A health care consultant and member of Managed Care magazine’s Editorial Advisory Board says that under health reform, pharmacies will have a greater need to balance clinical and economic considerations. The less expensive drug might not always be preferable. Video F. Randy Vogenberg RPh PhD’s blog

Studies suggest that U.S. physicians are hesitant to put patients on insulin therapy, but these pens may offer value by improving control Express Scripts, the mega PBM, reports that the 2012 drug trend for traditional medications declined in 7 of the top 10 traditional classes. In part that decline stems from patent expirations for blockbuster … Read more

Inter-Rater Reliability Testing For Utilization Management Staff Sue McQuillian, FSA Covering Risk But Not Risky Behaviors: A Critical Review of the Arguments for Insurance Coverage for Smoking-Cessation Therapies Cyril F. Chang, Ph.D. A Comparison of Diabetes Patients’ Self-Reported Health Status With Hemoglobin A1c Test Results In 11 California Health Plans Jeffrey Wasserman, Ph.D. ; Gifford Boyce-Smith, M.D. ; David … Read more

C. quinquefasciatus inhabits the southern U.S. New research indicates that another common mosquito may be able to carry the Zika virus, according to a Reuters report. The mosquito species Aedes aegypti is considered to be the main transmitter of Zika infections, but scientists in Brazil have announced that they were able to infect another species, Culex quinquefasciatus, with … Read more

Many patients with private insurance who are taken to the hospital by ambulance also feel that they are being taken to the cleaners. An investigation by Kaiser Health News (KHN) finds patients are stuck with exorbitant out-of-network bills because the ambulance companies and insurers had not hammered out a contract. The ambulance companies say that … Read more

An experienced negotiator and lawyer describes in detail how health plans that contract with PBMs can get a better deal For more than two decades, every managed care organization in this country has struggled to control its ever-increasing prescription coverage costs. Years ago, MCOs expanded their insurance fraud units to try to control drug costs. … Read more

Administration Anesthetic and Analgesic Drug Products Advisory Committee and Drug Safety and Risk Management Advisory Committee voted in support of approval of ALO-02 extended-release capsules because of the suggested sign,”direction of pain severe enough to take daily, aroundtheclock, longterm opioid treatment and also for which alternative therapy plans are insufficient” Addition of abuse-deterrent tagging for … Read more

Elelyso, derived from plant-cell technology, avoids many of the problems encountered when mammalian cells are used to create drugs Many of our readers can remember their parents telling them to “eat your carrots because they are good for you.” That advice has taken on a totally different meaning with the May 1 FDA approval of … Read more

In an ideal world, payers and providers would be on the same page when it comes to ANSI X12, version 5010 compliance and ICD-10 code readiness. But a recent survey conducted by the Healthcare Information and Management Systems Society (HIMSS) indicates that most providers will not be ready to test their electronic health information systems … Read more

However, There happen to be many false promises relating to it illness through time, additionally, it is smart to take care of statements — such as a published on the web by the diary, Chest — together with warning. Even a 48-year-old woman came with an acute instance of sepsis — swelling often set off … Read more

Company revises tens of thousands of analyses   Embattled blood-testing company Theranos Inc. has informed health regulators at the Centers for Medicare and Medicaid Services (CMS) that it has dumped all of the results obtained with its Edison testing devices in 2014 and 2015, according to a report in the Wall Street Journal. The company also … Read more

High costs mean a sea change in cancer management is urgently needed, and these tools can chart the way without eroding the physician’s role William J. Sullivan, MBA MANAGED CARE June 2012. ©MediMedia USA High costs mean a sea change in cancer management is urgently needed, and these tools can chart the way without eroding the physician’s … Read more

Making hospitals pick up the tab for patients who are readmitted because of infections contracted in those facilities on a previous visit doesn’t seem to improve outcomes, says a study of a policy implemented by the Centers for Medicare & Medicaid Services several years ago. “Effect of Nonpayment for Preventable Infections in U.S. Hospitals,” published … Read more

‘High Quality Saves Money,’ Or So the Story Goes Stakeholders, including Uncle Sam, are betting billions on an assumption that’s worked only in some instances and under specific conditions Are We Finally Getting Serious About Medical Errors? Hospitals have made astonishingly little progress, but CMS is forcing the issue FDA Approvals of Old Drugs Put … Read more

If you’re into health care policy and law, tomorrow is your Superbowl, World Series, and World Cup all rolled into one. Oral arguments for King v. Burwell are scheduled to start tomorrow at 10 a.m. As Richard Mark Kirkner explained in our February issue, the case could uphold the ACA or severely crimp the law by eliminating premium subsidies in the 34 states that … Read more

MANAGED CARE OUTLOOK Osteoarthritis, type 2 diabetes, stroke, Alzheimer’s disease, dementia, respiratory conditions, hypertension, certain cancers, and heart, liver, and kidney diseases all have something in common: Obesity contributes significantly to their prevalence. “In the United States, more than two thirds of adults are overweight or obese, and obesity is a leading factor in preventable … Read more

GOP takes heavy fire over pre-existing conditions The Senate could potentially vote on the latest repeal-and-replace plan for the Patient Protection and Affordable Care Act (PPACA) next week. The bill has won mixed reviews inside and outside Congress, according to a report by The Hill. The proposal, sponsored by Senators Lindsey Graham (R-South Carolina) and … Read more

March 1. That’s the deadline for the Bipartisan Commission on Medicare to make recommendations on how to overhaul the nation’s most beleaguered health care program. Yet the commission still seems almost light years away from achieving the broad consensus it has sought for many months. A majority of commissioners favors replacing the current system with … Read more

Online tools and an emphasis on patient-provider communication encourage more utilization of preventive medicine Aetna officials didn’t exactly cry “eureka!” when they released results of a study of their consumer-directed health plans, but they were proud of the results: Employers that replaced traditional PPOs with Aetna’s HealthFund plans saved $22 million over five years for … Read more

Building on a similar effort in California, Catalyst for Payment Reform is proposing a standardized set of 50 ACO measures. Some of the country’s largest purchasers are taking it to their health plans. Purchasers want IHA-PBGH measures but “also have some context-setting questions, like what was the spend on my people in the ACO” compared … Read more

The government is closely watching drug companies’ marketing practices where they intersect with federal health care programs. While the rules were drafted for drug manufacturers, health plans, too, should be vigilant. Don’t be fooled by the title of the Office of Inspector General’s “Compliance Program Guidance for Pharmaceutical Manufacturers.” The draft guidance not only covers … Read more

Hospitals are looking for a little love from commercial health plans but they’re not getting it, according to a survey by the Advisory Board Company. Denials of commercial insurer claims as a percentage of total denials increased between 2013 and 2015 even as the volume of commercially insured patients has stayed constant in both inpatient … Read more

When diet is not enough, a well known metabolic disorder can now be managed better through medication Thomas Morrow, MD Phenylketonuria (PKU) is a disease that most of the readers of this column have probably heard about as a result of having their own children screened for the condition at birth. It is an inherited … Read more

Full text available in PDF ABSTRACT Purpose. The medical cost of diabetes in the United States in 1997 was at least $98 billion. This study illustrates the behavioral change and medical-care utilization impact that occurs in a community-based setting of a diabetes disease-management program that is applied to program participants in a health insurance plan’s health … Read more

By Jean Lawrence Contributing Editor Would you believe that one in three physicians has no set policy for informing patients of abnormalities that show up in their diagnostic test results? “I’d believe it,” says a 52-year-old patient with experience in several Southwest HMO and preferred-provider organization plans. “I’ve had a terrible time getting my test … Read more

The Census Bureau reports that the number of Americans without health insurance dropped from 44 million in 1998 to 42 million in 1999, thanks in large part to a boost in the share of employers offering job-based coverage. Sixty-three percent of Americans received health benefits last year, up from 60 percent in 1998. A University … Read more

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