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

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

Standard & Poor’s expects the health insurance industry sector to continue to improve its credit rating in the second half of the year, according to its report “Rosy Midyear Outlook for U.S. Health Insurance in 2005.” This healthy glow can be attributed to a variety of factors, according to Shellie Stoddard, a credit analyst at … Read more

Type Title Author Story Dealing With Providers Always Takes Balance webadmin Story Prescription Drug Reimportation: Panacea or Problem? webadmin Story When Should Insurers Cover Off-Label Drug Usage? webadmin Story How MCOs Can Get Optimal Value from Their Pharmacy Benefit Managers webadmin Story What’s Good for the VHA Is Not So Good for Medicare webadmin Story … Read more

State lawmakers want hospitals to reveal what they’ve negotiated with health plans for lists of services that grow ever longer A few weeks ago the North Carolina legislature significantly upped the ante on what qualifies as price transparency in the health care industry. Lawmakers easily passed a bill that requires hospitals in the state to … Read more

Outcomes-based Pricing Program Puts Money in Beneficiaries’ Pockets Harvard Pilgrim’s program gives rebates to beneficiaries if Repatha doesn’t help them avoid a heart attack or stroke. Tom Price, the ACA’s Ardent Foe, Pushes For Repeal and Replace–With a Smile HOWARD WOLINSKY Affable and engaging, the new HHS secretary is a staunch conservative who says ACA … Read more

The issue is how extensive the list of covered medications should be for the new Medicare pharmaceutical benefit. The stakes are enormous. The United States Pharmacopeia isn’t what you’d consider a controversial organization. But when Congress selected USP to develop a model drug formulary that could be adopted by pharmacy benefit managers and health plans … Read more

U.S. spending on diabetes medications galloped to $10.1 billion in 2015, a 30% increase over 2014 expenditures, according to the drug spending report that IMS Institute for Healthcare Informatics released last month. While there is rapid growth in the utilization of all diabetes medications, especially insulins, the spending figure might be misleading because, according to … Read more

Self-referral is not the biggest contributor to the growth of in-office imaging by physicians, according to a report prepared by the Lewin Group for a coalition of physicians and medical groups. Rather, it’s the immediate access to imaging results and the expanded uses for diagnostic imaging that drive the growth of these technologies. The report … Read more

Considerable instances of stroke and rips at the lining of blood in the neck and head have happened in patients with multiple sclerosis (MS) briefly after they received Lemtrada. These issues may result in permanent disability as well as death. Because of this, we’ve inserted a brand new warning about those risks for the information … Read more

THE FORMULARY FILES Sovaldi ushers in wave of costly hepatitis C drugs The problem is not how to decrease specialty pharmacy cost; that will never happen. Rather, it is how to reduce the rate of increase in specialty pharmacy cost. Payers face a market characterized by a growing number of specialty drugs with high price … Read more

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

By John Marcille A few years ago some enterprising writer decided to do a story that was so obvious that almost everybody else missed it. Go to a major league baseball game and you’ll see that the baseballs themselves are used and discarded with the frequency usually reserved for tissue paper during flu season. Does … Read more

Many PAs and NPs have ascended into places of direction within their HM classes or medical systems, sometimes even trapping the doctors. The Hospitalist linked together with both six PA and NP leaders at hospital Medicine to go over their career paths in addition to the type and range of their tasks. They clarified leadership … Read more

Providers gain capitation ground Collecting information is one thing; interpreting it is another. National Health Information polled 466 provider groups; among the questions was, “If you have renegotiated a contract in the last 12 months, has the capitation rate increased, decreased, or stayed the same?” Answers given by providers contracting with HMOs seem to indicate … Read more

Don’t look now but consumer directed health plans (CDHPs) and high-deductible plans may be working — almost too well — according to results of the largest study involving these types of plans. Results from a year-long Rand study suggest that families that have deductibles of at least $1,000 have health care spending that is 14 … Read more

A Sizable Analysis of a fresh sort of cholesterol medicine in Merck & Co Inc found it cut down the chance of coronary attack and passing by a small 9%, while inducing a build from this medication in fat cells, which makes its commercial future unclear. REUTERS/Jeff Zelevansky Researchers, Who introduced the findings into some … Read more

Reports of the death of the Agency for Health Care Policy and Research, to borrow from Mark Twain, appear to be exaggerated. After flirting with extinction, AHCPR may well be making a full recovery, thanks to newfound bipartisan support in Congress. Under pending legislation, AHCPR, once the target of elimination by the Republican leadership, would … Read more

Can primary care physicians persuade health plans and Medicare to accept their version of the chronic care model? When the American College of Physicians launched its advanced medical home model at a news conference in January, movie buffs in the audience compared the presentation to Back to the Future. Indeed, while the medical home concept … Read more

Palbociclib/letrozole combo improves survival versus letrozole alone Positive results have been reported from a phase 3 trial of palbociclib (Ibrance, Pfizer), an oral, first-in-class inhibitor of cyclin-dependent kinases (CDKs) 4 and 6. The study met its primary endpoint by demonstrating an improvement in progression-free survival (PFS) with the combination of palbociclib and letrozole compared with … Read more

Despite the recent news that Medicare will not exclude erectile dysfunction drugs from coverage limitations, health plans responded with a ho and a hum. That’s because when sildenafil (Viagra) arrived on the scene in 1998, health plans and employer groups got together and hashed out a benefit package that took into account the risks, benefits, … Read more

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

Specific Monoclonal Antibodies Ensure Extreme Sensitivity, Accuracy Quidel has received 510(k) clearance from the FDA to market the Quidel Triage® TOX Drug Screen, 94600, a fluorescence immunoassay for the determination of the presence of drugs and/or metabolites in human urine. The test is to be used with Quidel’s Triage® MeterPro instrumented system. Drug abuse in the … Read more

ACE-083 May Improve Strength in Target Muscles, Enhance Quality of Life The FDA has granted an orphan drug designation to Acceleron Pharma Inc.’s ACE-083, a locally acting “Myostatin+” muscle agent, for the treatment of Charcot-Marie-Tooth (CMT) disease. Clinical trials to date have demonstrated that treatment with ACE-083 results in substantial increases in muscle volume in … Read more

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

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

Authors evaluate rosuvastatin/ candesartan/ HCTZ combo Statins may significantly reduce adverse cardiovascular events in people with average cholesterol and blood pressure (BP) levels who are considered to be at intermediate risk for cardiovascular disease, while the use of BP-lowering medications may be beneficial only in hypertensive patients, according to three reports from the HOPE-3 trial. … Read more

Exelixis, Inc.. Now declared that the U.S. Food and Drug Administration accepted CABOMETYX® pills for its enlarged indication of individuals with advanced renal cell carcinoma. RCC is by far the most common type of lung cancer in adults. Now’s tag expansion follows the very first FDA endorsement of CABOMETYX at April 20-16 for its cure … Read more

Many jobs available to young adults pay little and do not include health benefits. Those are two reasons cited to explain why 13 million young adults lacked coverage in 2003. That’s 2.2 million more than those who lacked coverage in 2000, according to a study by the Commonwealth Fund. Those 19-29 years old who come from … Read more

For obese people Having diabetes, doctors have been Offering gastric by pass operation for a means to shed excess weight and control blood sugar levels. Shortterm answers are frequently striking, but questions have stayed on the longterm added benefits of such surgeries. Now, a big, international study has a few responses. Right after gastric bypass … Read more

Color charts Also available as PDF The Medical Group Management Association tracked 30,835 providers, mostly physicians, and 1,609 specialty groups to gauge how their salaries grew between 1994 and 1998. Despite a dip in 1997 — and the spread of managed care — specialists’ salaries increased a bit faster than primary care physicians’ salaries over … Read more

There’s plenty of ill will between hundreds of Denver-area physicians and PacifiCare of Colorado, in the aftermath of the collapse of a management company that represented four practices. The PPM, Millenial, was a middleman between health plans and the physician groups that are composed of 190 primary care doctors and 1,000 specialists and that serve … Read more

Community health information networks failed in the 1990s. Today’s newer version — regional health information organizations — seeks to form more collaborative relationships. Let’s say you’re an emergency room physician and a new patient comes in to your examination room. You have never examined him before, nor has he ever been to this hospital. You … Read more

Canadian study adds to data on controversial topic If they had a choice, most patients with chronic pain and those receiving mental health drugs would rather turn to cannabis instead of their prescribed opioid medication, according to new research by the University of British Columbia and the University of Victoria in Canada. The study tracked … Read more

With, till today, just torso surgical procedures. The Flourish Pediatric Esophageal Atresia Apparatus is an Amazing option to conventional Chest surgical processes. No process or apparatus is Free from adverse Events, however the consequences of the really are really so much noteworthy.

Is related to a lesser risk for lung cancer, based on a report published online Sept. 25 at JAMA Network Open. Health Sciences at Bethesda, Maryland, and colleagues conducted a 60-year followup of a clinical trial to test whether BCG vaccination is related to cancer levels at another diagnosis of an BCG clinical trial. The … Read more

HMOs should adopt a conflict-management, rather than dispute-resolution, approach to patient complaints. Kathy L. Cerminara, JD It is now clear that many patients in managed care organizations have a right to external review of certain managed care decisions in certain states. The Supreme Court ruled last June, in Rush Prudential Insurance v. Moran, that managed … Read more

This thesis deals with how organizations in the pharmaceutical industry will be increasingly nearing the growth of inventions and also what benefits that there are implementing Open Innovation strategies. Both pharmaceutical firms are equally tremendously Based on creations and also possess Approached different approaches involving Open Innovation and all such plans are analyzed from the … Read more

His roots are modest. His ideas for Aetna, health care, and even capitalism are not. For a person of modest means who says he never really followed a defined career path, Mark Bertolini has had one resume, said he never looked for a job, and went to Cornell for his MBA because it was the … Read more

It will take some time to fully digest the 592 pages of new rules for the Medicare Shared Savings Program (MSSP) ACOs. You can get started and read them for yourself here. But few items pop out even in an Evelyn Wood reading of the first 30 or so pages. CMS is going to allow the Track … Read more

New Treatments For Eye Disease Download supplement This supplement focuses on recent significant advances in the treatment of patients with eye disease. This series of articles by faculty of the University of Illinois at Chicago cover the use of topical, systemic, and biologic agents for allergies, diabetic retinopathy, macular degeneration, glaucoma, and more. Highlights: Pharmacotherapy … Read more

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

Formulary design, contracting, and other strategies will be key to maximizing the opportunities of brand patent expirations Lipitor’s anticipated patent expiration in November will be a blockbuster event in further tempering the escalation of pharmacy costs, but there may be other benefits. Lipitor (atorvastatin) is the world’s biggest drug ever says George Van Antwerp, general … Read more

In January, a new venture investment fund opened in Boston with $42 million in its pocket and a goal of raising $80 million within two years. The new fund, called the JDRF T1D Fund, quickly invested in three early-stage start-ups. Just like traditional venture capital funds, the T1D Fund plans to work closely with start-ups … Read more

Presenteeism — the condition of being on the job, but giving less than 100 percent — is fertile ground for health plans with a suitable product. About 100 physicians in South Charleston, W.Va., have been offered a stake in keeping 10,000 Dow Chemical employees as productive as they can be. By going the extra mile … 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

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

The Business Case for Process Improvement 3 Success Stories Joseph Burns Can Arthroplasty’s Costs Be Contained? Try ‘bundled payments, accountability, and consumer involvement,’ one surgeon advises Carol Milano Stressed States Open Doors to Medicaid Managed Care Plans are increasingly trusted with management of the ABDs — aged, blind, and disabled John Carroll US Family Health … Read more

MANAGED CARE March 2001. ©MediMedia USA In a dramatic attempt to keep a lid on health care premiums, the California Public Employees’ Retirement System threw out every bid it received from health plans competing for a chunk of its business in 2002. CalPERS says it was offered premium hikes ranging from 5 to 40 percent. Plans were … Read more

The AIDS Drug Assistance Program (ADAP) has become a critical source of prescription drugs for low-income people with HIV/AIDS who have no or limited prescription drug coverage. There are 57 ADAPs, yet nearly 30 percent do not include coverage of all FDA-approved antiretroviral (ARV) therapies on their formularies, and South Dakota does not provide any … Read more

The retreat from tightly managed care in recent years has left casualties on the insurance battlefield: people with low incomes and chronic illness. So says a report by the Center for Studying Health System Change titled “Patient Cost Sharing: How Much Is Too Much?” For many, the study implies that that question has already been … Read more

COVER STORY Disruptive Innovations That Will Change Your Life in Health Care The innovations that we list here are not unfamiliar, but don’t underestimate them. As they mature, they will have strong effects. In 1995, Harvard business school professors Clayton Christensen and Joseph Bower put “disruptive technologies” in the business lexicon by introducing the term … Read more

Naturally, doctors are more likely to buy into a physician-led DM program. Rewarding them for resulting lower medical costs keeps them in the game. By MargaretAnn Cross If a patient whose physician works for Harvard Vanguard Medical Associates ends up in a hospital with congestive heart failure, odds are high that the patient will be … Read more

National Council for Behavioral Health calls for reforms Psychiatric services are in a state of crisis in the United States, and stakeholders in the health care industry have roles to play in fixing the problem, according to a report from the National Council for Behavioral Health (NCBH). The report was prepared by the nonprofit group’s … Read more

There are ways for low-income groups to avoid paying top dollar for prescriptions. Here’s one way physicians can educate consumers. The rapid escalation in the price of prescription drugs presents some patients with a dire choice: filling a prescription or buying groceries. Instead of skimping on food or skipping the rent, patients who can’t afford … Read more

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

By now, most health-care decision makers are pretty well agreed that more care does not mean better care. And they also are agreed that when a provider charges a higher price, that is not necessarily related to the quality of the service. But at the same time, we are greatly challenged by the fee-for-service method … Read more

Every stock or collateral desires an industry of sellers and buyers as a way to move ahead the trades. Economy manufacturers are high-volume traders who literally”create a market” for securities by consistently standing at the willing to purchase or sell. They profit upon the bidask spread plus so they benefit the market with the addition … Read more

Aetna’s chief medical director for Medicare draws on years of experience to chart opportunities and challenges of the new legislation’s focus on innovation You can always learn something from a pilot program — even an unsuccessful one, believes Randall Krakauer, MD, national Medicare medical director at Aetna. He has spent the last eight years figuring … Read more

Patients refuse to take responsibility, and every other player in the health care system is reluctant to take charge Gail Dudley, DO Managed Care’s July cover story, “Employers Push Plans in Direction of Wellness,” should fall under the “duh” principle. Since prior to my first day in medical school in 1982, I have been certain … Read more

At a glance Medstat Quality Catalyst Ann Arbor, Mich. Goal: Provide comparative information on quality of different types of health plans without relying on plans’ self-reported data, which can be perceived as biased Strategy: Survey 50,000 benefits managers, enrollees and physicians in six metropolitan areas, using lists of employees and physicians provided by employers. Add 15 to … Read more

State attorneys general have been making national news lately — not so much for such bread-and-butter responsibilities as prosecuting criminals or busting ripoff artists — but because of health care issues. That’s because virtually every item in the news about health care coverage lately, from HMO horror stories to health plan consolidation, from lawsuits to … Read more

“Paper records are fading away,” says a PricewaterhouseCoopers study, “Needles in a Haystack: Seeking Knowledge With Clinical Informatics” (http://bit.ly/AnS5dC). One reason is money. Under the American Recovery and Reinvestment Act of 2009 (“the stimulus”), the government has paid $2.5 billion to 800 hospitals and 33,000 physicians for using electronic health records. “Thousands more are in … Read more

MANAGED CARE February 2003. ©MediMedia USA Although prescription drug spending was only 14 percent of total Medicaid spending in 2002, that’s the place where states are looking to save money to shore up growing deficits in their budgets. “I think it’s fair to say almost all 50 states will consider some aspect of this issue,” Richard Cauchi, … Read more

Threat is “real, ever-present, and continually changing,” official says The FDA has issued a 30-page document addressing cyber vulnerabilities in medical devices, providing manufacturers with guidelines for fixing security bugs in equipment, including pacemakers, insulin pumps, and imaging systems, according to a Reuters report. The agency released the guidance as it investigates claims that heart … Read more

As expected, the Department of Health and Human Services promulgated privacy regulations after Congress failed to do so itself. The regulations, which apply to providers, plans, and billing companies, restrict the release of information without patient consent and impose fines of up to $50,000 per violation. The regulations do not supersede any state laws that … Read more

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

After working without a contract since Dec. 30, 1996, Kaiser Permanente nurses in Northern California staged a two-day strike Jan. 28 and 29, leaving Kaiser hospitals scrambling to meet inpatient care needs, instituting mandatory overtime and canceling elective surgeries. Nurses say that they want a contract that guarantees them a voice in staffing and that … Read more

An affordable option for integrated health care bridging private U.S. insurers and Mexico’s social security system would save American employers money while providing better care to Mexicans who work in the U.S. but whose families live in Mexico, according to a study. The Mexico-USA Cross-Border Health Insurance Initiative, a joint project of the Academy for … Read more

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 tenure, but analysts think Humana’s … Read more

MANAGED CARE October 2008. ©MediMedia USA A peptide fusion protein can stem the tide of abnormal, excessive bleeding Thomas Morrow, MD Platelets are amazing components of our bloodstream. Not actually cells (they lack a nucleus and major metabolic machinery) and available in large quantities, they respond in a moment’s notice to a leak in our blood vessels … Read more

Increasingly over 500,000 clinicians That Engaged from the federal government’s Doctor Quality Reporting System (PQRS) is likely to soon be struck by a two% Medicare punishment this season because they failed to meet application requirements. A few 501,933 clinicians are subject to some 2% Reduction within their 20 17 Component B flat-rate charges predicated on … Read more

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

When the Medicare Part D program began in 2006, it increased drug coverage for Medicare beneficiaries from 59 percent to 89 percent, says Christopher C. Afendulis, PhD, a lecturer in the department of health care policy at Harvard Medical School. Afendulis and colleagues sought to determine whether this change reduced hospitalization rates for conditions sensitive … Read more

THE CONTRARIANS Wendell Potter: Not-for-Profit Health Insurers Will Come to Dominate the Market “The not-for-profits are spending considerably more for patient care and having a much easier time meeting the MLR [medical loss ratio] rules than the for-profits are.” Could small not-for-profit health insurers overtake the nation’s largest publicly traded in terms of market share? … Read more

Experts support 81 mg per day in adults The U.S. Preventive Services Task Force (USPSTF) has released a final recommendation statement on the use of aspirin for the primary prevention of cardiovascular disease (CVD) and colorectal cancer. Evidence shows that low-dose aspirin use is most beneficial for adults 50 to 59 years of age, according … Read more

Health plans want savings, and suspect they’ll find some in hospitals — which, for their part, say the Balanced Budget Act has stripped them clean. By Frank Diamond Senior Editor Health care follows the money. Within the last four or five years, HMO executives engaged in tracking revenue have turned toward hospitals, looking for that … Read more

Hospital at Home Saves 19% In Real-World Study The program is not for everyone, but patients who qualify appear to have superior outcomes and lower costs Jack McCain Hospital at Home: Compelling Findings, But Replicable in Other Systems? We invited experts from around the country to weigh in on the strengths and weaknesses of Hospital … Read more

Drugs used to treat diabetes could also be used to treat Alzheimer’s disease (AD), and vice versa, according to new research from the University of Aberdeen in Scotland. It’s the first study to show that AD can lead to diabetes, as opposed to diabetes occurring first, as was previously thought. The investigators found that AD … Read more

Consent to Lartruvo using doxorubicin to treat adults with specific forms of soft tissue sarcoma, which are cancers that grow in joints, tendons, tendons and other soft tissues. Lartruvo is qualified for use with the naturopathic chemotherapy medication doxorubicin for treating patients using STS that cannot be treated with chemotherapy or radiation and that have … Read more

Germany has a reputation for being among their better & most extensive healthcare systems in the whole world, providing its residents with health, sick cover and longterm medical care insurance policy coverage. Approximately 90 percent of the populace is a compulsory or a voluntary participant of the general health strategy as the remainder have health … Read more

Health Care Reform in the U.K.: Managed Care by Another Name? Not quite. In a politically driven system of management, the inevitable result was that market forces were ignored — to disastrous effect. Robert Royce Byte by Byte, Harvard Pilgrim Choked on Unhealthy IT Systems Harvard Pilgrim Health Care learned the hard way what Oxford … Read more

  Value-based purchasing in health care has reached the point of no return, no matter who wins the White House or if the ACA were to get scrapped. The health care reform law has enabled or inspired so many changes in the infrastructure of American health care — ACOs and integrated delivery systems, federal and … Read more

BY ANNE BILODEAU Contributing Editor It’s not a new idea, the notion that doctors can improve their autonomy, clout and profit margins by circumventing HMOs to contract with employer groups themselves. But in 1996 the concept has taken on a new urgency, as two Midwest employer coalitions have announced new direct contracting initiatives, and doctors’ … Read more

Mr. Henderson is 72. He is worried about his prostate. His biopsy came back equivocal and his MRI negative, and his wife wants him to have an operation instead of routine laboratory testing. Mr. Henderson has been married for 51 years and is with his wife in Dr. Beale’s office. “I don’t know, Doc. Maybe … Read more

John Carroll Contributing Editor Pharmacy benefit managers are under fire from many corners. What will the push for transparency mean for the industry? MANAGED CARE September 2002. ©MediMedia USA Pharmacy benefit managers are under fire from many corners. What will the push for transparency mean for the industry? John Carroll Contributing Editor David Halbert arrived in New … Read more

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

Three decades after Hawaii was supposed to have put a controversial end to a chronic problem by making employers cover more people, guess what persists? John Carroll MANAGED CARE December 2003. ©MediMedia USA Three decades after Hawaii was supposed to have put a controversial end to a chronic problem by making employers cover more people, guess what … Read more

Reports of a new survey on “IFDSs” from the accounting and consulting firm Ernst & Young may seem to require adding a whole new alphabet-soup entity to your health care vocabulary. Turns out it’s not quite that bad: “Integrated delivery and financing systems” is an umbrella term for “any type of managed care organization that … Read more

It’s hard to open any health-related publication these days and not find stories about accountable care organizations (ACOs). Commentary ranges from extolling ACOs as our last, best hope for achieving high-value care in the U.S., to others criticizing ACOs as a thinly disguised return to the 1990s model of managed care and HMOs. While it’s … Read more

Government overpays specialists relative to primary care physicians and thereby exacerbates the shortage of primary care physicians, according to researchers at the Cambridge Health Alliance and Harvard Medical School. The study, released online by the Journal of General Internal Medicine, will be printed in September. The data are from the 2004 Medical Expenditure Panel Survey, … Read more

The Impact of Molecular Diagnostics on Treatment Pathways, Outcomes, and Cost Adjuvant chemotherapy can improve survival in patients with early-stage breast cancer or colorectal cancer who have undergone surgical resection, but the benefit from this treatment is not universal. A distinguished panel of experts addresses the advance in molecular diagnostic testing and its impact on … Read more

Un-necessary cesarean section deliveries (c-sections ) may diminish whether many different interventions targeting patients, caregivers and physicians were executed, implies an upgraded inspection of present research. “For ladies, concentrated pre natal educational aid programs can help lessen unnecessary caesarean section, and this also affirms the belief that women gain from having sufficient facts to make … Read more

Extremist ideologies which may cause terrorism and violent extremism. Enhanced preventative activities can, subsequently, address social anxieties and extremist ideologies and hence cultivate integration and peaceful coexistence in people and communities. Throughout the Promoting addition and providing chances for younger people in danger throughout education, culture, sports and youth may further result in the avoidance … Read more

Calculating healthcare businesses’ voluntary disenrollment rates from easily obtainable data and examined the degree to which these speeds varied one of the plans, concentrating on: disenrollment rates for most Medicare HMOs operating in 1996; the disenrollment rates of plans operating at the very same markets; disenrollment rates of relatively fresh plans; and also the proportion … Read more

When it’s time for a session, your therapist’s face is on your phone or computer instead of in the room. Telemental health doesn’t mean the end of in-person sessions, but it’s increasingly part of the therapy mix. Robert Chalfant, MD, of Colorado West Mental Health, says a large part of his practice involves video sessions … Read more

The SGLT2 inhibitors and GLP-1 agonists may have a direct effect on heart failure and cardiovascular outcomes. Cardiovascular disease is perhaps the most dangerous consequence of diabetes, despite the ravaging impact that neuropathy, nephropathy, and retinopathy can have on people with the disease. About two out of three people ages 65 or older with diabetes … Read more

MANAGED CARE May 2001. ©MediMedia USA Humana is phasing in a four-tier formulary that categorizes prescription drugs by costs, rather than generic or brand status. The higher the drug’s acquisition cost — regardless of whether it’s a branded or generic product — the higher the tier it lands in. The MCO says the structure gives it more … Read more

Since the passage of the ACA in 2010, health insurers have been slowly but surely losing one of the chief advantages of their Medicare Advantage (MA) plans: a 14% bump over what traditional Medicare paid per beneficiary. Next year, the difference is scheduled to disappear entirely, when MA payment per beneficiary will match what traditional … Read more

Unimpressive performance combined with the dangerous shortcomings of older medications keeps insurers wary. Two new medications approved this summer are pharma’s latest attempt at a wonder weight loss drug in a class where the performance of past agents has been awful. Several, most famously fenfluramine and sibutramine, were yanked for major safety reasons. Only a … Read more

The Health Insurance Portability and Accountability Act need not endanger outcomes that depend on data access unless you let it. Jack A. Rovner Last November, the National Committee on Vital and Health Statistics reported to the Department of Health and Human Services that there exists “an extremely high level of confusion, misunderstanding, frustration, anxiety, fear, … Read more

Contrary to the highly misleading picture painted by critics, the 340B drug discount program is working as Congress intended and helping millions of underserved Americans receive better healthcare every year. The pharmaceutical industry has gone to great lengths to misconstrue how the program functions in an effort to vilify safety-net hospitals. These are the urban … Read more

Name Last modified Size Description Parent Directory 11-Jan-2005 13:10 – 0002.news_premiuminc..> 09-Apr-2003 23:27 1k 0002.news_irp.html 09-Apr-2003 23:27 1k 0002.news_pharmacyco..> 09-Apr-2003 23:27 1k 0002.news_firstmajor..> 09-Apr-2003 23:27 1k 0002.compmon.html 09-Apr-2003 23:27 2k 0002.news_comeback.html 20-Jun-2003 16:09 2k 0002.news_tenncare.html 20-Jun-2003 16:09 2k 0002.news_heels.html 09-Apr-2003 23:27 2k 0002.news_headlines…> 20-Jun-2003 16:09 2k 0002.news_pcps.html 09-Apr-2003 23:27 2k 0002.outlook.html 20-Jun-2003 16:09 2k 0002.news_warning.html … Read more

In 2013, the FDA proposed changing labeling rules to create “parity” between generic and brand-name drug makers for how they update their labels, exposing generic companies to legal liability if they fail to warn of a drug’s risks. The rule was widely expected to be introduced this spring, but the agency has decided to put … Read more

The FDA has given Priority Review status into the INGREZZA NDA having a Prescription Drug User Fee Act target activity date of April 1 1, 20 17. The NDA to get INGREZZA comprises the outcomes from the Kinect two and also Kinect 3 clinical trials that assessed more than 330 tardive dyskinesia patients. Statistics from … Read more

HEDIS: LOOKING AT THE NUMBERS A Managed Care magazine analysis of Quality Compass 98 — the National Committee for Quality Assurance’s annual compilation of HEDIS data — has blown the dust off of some controversial generalizations about the health plan industry. Our study of Quality Compass data indicates that on the whole, not-for-profit health plans … Read more

People talk of mergers as if they were all done when the ink dries. But the real secret to a successful merger comes afterward. Everyone hears about the people who are thinking about putting a merger together, and they get all kinds of kudos when they sign the papers to conclude a deal. But not … Read more

The increase in the number of catastrophic claims is shocking, but there are things that insurers and employers can do to protect themselves Charles Crispin tells the sad tale of a commercial health plan that opened for business in January 2006. A month later, a hemophiliac member started bleeding, requiring large doses of a blood … Read more

The World wide outbreak of Zika virus has long turned into a significant public health problem involving expectant mothers and their babies. The illness isn’t severe in many instances nonetheless, there’s evidence that illness during pregnancy might be related to fetal bronchial disorders. Besides microcephaly and different malformations, a few particular lesions in the central … Read more

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

Don’t dismiss this development in Web communication. Blogs — the best of them — conduct serious and extensive discussions of health care policy and provide important new information. Alan Adler, MD Medical Director, Independence Blue Cross Blogs have been around for almost a decade now, yet many professionals in health care have failed to recognize … Read more

Goal: Lower health care costs for small and large employers in Louisiana Number of employers represented: 100 Number of employees involved: 250,000 Amount, based on experience of other states, that the purchasing coop hopes to save employers: 10—20% Although its bayous are filled with deceptively drowsy ‘gators, Louisiana is also home to a number of large petrochemical companies, such … Read more

The National Committee for Quality Assurance will soon offer its blessing to disease management programs. NCQA is developing a DM certification program intended to recognize regimens that effectively manage chronic illnesses. The program will go live next year. Stand-alone DM vendors will be eligible for certification, as will in-house DM programs at health plans. Though … Read more

In Texas, doctors record their frustrations with managed care in a “Hassle Factor Log.” In Florida, they register them by calling a “Hassle Factor Hot Line.” Yet in Illinois, doctors would think such outlets for complaint were a flashback to the ’70s, when managed care was a new concept in most of the nation. In … Read more

Many Clinical Studies May Not Be Dependable Researchers and physicians are questioning the validity of information presented in the medical literature, saying that many of the findings presented are prone to bias or just plain wrong. In his much-publicized 2005 review, John P.A. Ioannidis, MD, looked at 45 studies published in major medical journals and … Read more

The Florida Medical Association and other physician groups in the state have sued Prudential Health Care Plan, charging that the HMO has illegally denied claims or delayed payment. The North Florida Obstetrical & Gynecological Association and the Florida Physicians Association joined in the suit, filed in late July in Duval County Court. The suit claims … Read more

A recent survey shows internists getting paid more per relative value unit (RVU) than physicians in family practice. The Resource-Based Relative Value Scale (RBRVS) is the prevailing model used today to describe, quantify, and pay for physician services. Medicare, Medicaid, and many private insurance companies use the RBRVS, and many practices and institutions enlist RVUs … Read more

Immunizations are a good deal for public health, but their growing number and rising costs pose a challenge for plans that must pay doctors for administering them It’s not the kind of truism you stitch in needlepoint and hang on the wall, but in health care almost every opportunity is also a problem. And the … Read more

The United States health system faces growing pressure to enhance Patient use of exceptionally effective, yet high priced, remedies. In Accordance with the wider policy change toward choice payment. Models for healthcare , there’s ongoing interest among Advertisers and producers at researching value-based payment agreements for medical and biotech instruments. VBAs, also known as”outcomes-based contracts,””performance- … Read more

January 2012 February 2012 March 2012 April 2012 May 2012 June 2012 July 2012 August 2012 September 2012 October 2012 November 2012 December 2012

A relatively new concept in strategic management provides a way to balance quality and customer satisfaction with costs and long-range goals. Judith A. Shutt Southwest Texas State University – San Marcos Full text available in PDF During the 21st century, successful health care management will depend on organizations and top executives balancing quality and customer … Read more

Health System Selects SNFs To Improve Overall Care Traditionally, hospitals and their integrated delivery networks (IDN) have focused very little on any care delivered outside their walls. But that rather blinkered approach to health care is becoming increasingly out of date. These organizations are now being held responsible for hospital readmission rates, and that’s a … Read more

Name Last modified Size Description Parent Directory 28-Aug-2000 11:10 – 9808.news_whatstheri..> 29-May-2000 11:52 1k 9808.news_newdrugs.s..> 29-May-2000 11:52 1k 9808.washington_gord..> 29-May-2000 11:54 1k 9808.washington_tele..> 29-May-2000 11:54 1k 9808.news_wheres.shtml 29-May-2000 11:52 1k 9808.news_headlines…> 29-May-2000 11:52 1k 9808.states_kentucky..> 29-May-2000 11:53 1k 9808.washington_some..> 29-May-2000 11:54 1k 9808.compmon.shtml 29-May-2000 11:52 2k 9808.washington_medp..> 29-May-2000 11:54 2k 9808.states_texas.shtml 29-May-2000 11:53 2k 9808.washington_take..> … Read more

They’re endangered by a brutal combination of factors, a report last August declared, but things may not be so bad as they looked then Timothy Kelley “A perfect storm”? To his credit, Joseph Zazzera, managing senior financial analyst at A.M. Best, didn’t use that cliché in a special August 2009 report he prepared for that … Read more

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

Mark D. Abruzzo, J.D. Alternative dispute resolution refers to a variety of methods for resolving disputes without resorting to litigation. Arbitration and mediation are the most common methods of ADR, although there are variations. ADR is not used nearly as much in health care as in many other industries. However, significant changes, along with ever-increasing … Read more

January 2008 February 2008 March 2008 April 2008 May 2008 June 2008 July 2008 August 2008 September 2008 October 2008 November 2008 December 2008

Immunization Alert The nation’s immunization system — especially with regard to adults — is in need of an overhaul before it collapses. Deadly, costly epidemics could be the alternative. Cover Story Did Clinton Get His Way? The president’s failed effort to overhaul health care was just a first-round failure. Some of what he pushed is … Read more

Hospitals now face stiff penalties and some health plans see this as a way to attain a long-sought goal A little more than two years ago, Victor Caraballo, MD, the senior medical director at Independence Blue Cross in Philadelphia, set out to hit the brakes on the flow of unnecessary readmissions to area hospitals. By … Read more

UnitedHealthcare study unveils some impressive numbers, and now the company sets its sights on prediabetes Frank Diamond Launching a value-based insurance design (VBID) program is a one-sided relationship in the beginning. The enrollee receives free medication and doctor visits, but the health plan won’t know where it will lead for at least two or three … Read more

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 because extrapolation depends … Read more

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

Primary Care as a Platform for Value MICHAEL D. DALZELL Quantifying the worth of primary care and its delivery are essential for raising its profile. New data and payment incentives may push us closer. Nurse Practitioners Can’t Do What Primary Care Docs Can Do ALAN ADLER, MD Nurse practitioners are wonderful, but they’re not doctors. The … Read more

Sometimes you can learn as much from the wastebaskets in a magazine’s office as you can from the gleaming new issues in the lobby. Notes from a meeting on this month’s cover are all that’s left of one editor’s proposal to symbolize the leisure time physicians gain when they accept a salaried position. That editor … Read more

Here in Chicago, of the rugged elbows and tattooed muscular shoulders that carry the Bulls, only basketball lets people believe we all live in the city that works. Basketball makes Neiman-Marcus shoppers and K mart shoppers believe that they share the same values. Amazingly, basketball creates a community. Driving across Chicago this week, I noticed … Read more

BIOLOGICS IN DEVELOPMENT Memo to P&Ts: Early approvals could be the new norm P&T committees often wait six months to a year before fully evaluating a new drug. The Food and Drug Administration’s new “breakthrough drug” designation doesn’t change that, but the appellation will almost certainly force P&T committees to review those products earlier than … Read more

Darren T. Binder, JD The privacy rule that was required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 established important standards and protections for the transmission of health information. For the first time, a set of national privacy standards was created to provide “all Americans with a basic level of protection and … Read more

Guideline writers are dialing back breast screening recommendations because of concerns about false positives and overdiagnosis. But advocates and some clinicians are pulling in the opposite direction—for more coverage, especially for 3D mammography. Breast cancer screening used to be something that pretty much everyone could agree upon. Now it is one of the more confusing … Read more

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

Both AHIP and the AMA address ways to give better care to 75 million Americans who struggle to follow directions Frank Diamond Managing Editor Common ground is prime real estate to those trying to gather the warring factions in health care under the banner “reform.” William Butler Yeats wrote that “the center cannot hold,” and … Read more

Not Exactly Onethird of Those 5 7 million Medicare beneficiaries Have Been Insured By personal Medicare Advantage plans — a substitute for government-run Medicare — and also national officials have estimated that the percentage increases to 41 per cent during the next ten years. The federal government pays the plans to supply medical services with … Read more

Seven health plans and 74 physician practices unite under a CMS program to bolster primary care In this period of health reform, physicians are being asked to take on more risk, but many worry that they may not be capable of doing so. To help with that, initiators of a program in Colorado hope to … Read more

And most don’t because the thinking is “my insurance will cover it.” Companies that sell computers, cloths, food, or most other items Americans buy are not required by law to post their prices. But many do anyhow because consumers are always out to save money. Except when it comes to health care, argues Scott W. … Read more

Former President Ronald Reagan said that the “most terrifying words in the English language are: ‘I’m from the government and I’m here to help.’” His ideological progeny, the current occupant of the White House, seems to be operating under the same assumption as the race to create association health plans (AHPs) picks up speed. President … Read more

Management of the uncontrolled asthma patient and case examples Full text in PDF Abstract Allergy is a significant component in many asthma patients. Omalizumab is a monoclonal anti-immunoglobulin E antibody for the treatment of allergic asthma. Clinical trials have shown that omalizumab treatment is associated with improved symptom control and reduced inhaled corticosteroid doses, resulting … Read more

What’s missing in recent reports of HMOs seeking 20- to 22-percent increases in premiums is just how less-than-thrilled health plans are to be asking for that much more money. “Any rate hike will obviously be tough on all insurance products within a given region just because the economy is too slow for employers to accept … Read more

Healthinsurance from the USA isn’t any application which will help pay for health care expenses, if privately purchased insurance policy , societal insurance policy , or perhaps a societal welfare program financed by the us government. In a more technical understanding, the word”medical health insurance” can be applied to describe any kind of insurance providing … Read more

Under new Medicare rules, searchable formulary Web sites now face tougher regulatory oversight With the promise, or threat, of seismic change in health care rattling everyone from President Obama down to the humblest coding clerk, it seems unfair that health plans must chase a moving regulatory target. But as another president — John Kennedy — … Read more

Building provider incentives around drug performance is one way health insurance plans can ensure optimal use Medication reconciliation is a cornerstone of efforts to improve medication safety, yet widespread implementation of procedures that work has been a problem. The Joint Commission, which accredits hospitals and other providers, established medication reconciliation as one of its national … Read more

His roots are modest. His ideas for Aetna, health care, and even capitalism are not. For a person of modest means who says he never really followed a defined career path, Mark Bertolini has had one resume, said he never looked for a job, and went to Cornell for his MBA because it was the … Read more

BY PETER WEHRWEIN Arthur Goshin, M.D., M.P.H., president of Health Care Plan, a prosperous, 160,000-member, not-for-profit HMO in Buffalo, recently went to what was billed as a negotiation session with a large hospital system. In theory, negotiation is a two-way street. In practice, this session was more like a one-way, limited-access highway–headed in the other … Read more

The Country’s ongoing opioid problem Includes Astounding physical And psychological costs to families and patients. However, the dollar cost to the overall health system was tougher to cancel. Presently a brand new report indicates an even significantly more than 1,300 per cent growth in spending health insurance within an short span period on patients having … Read more

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

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

SGLT2 inhibitor is available as Invokana and Invokamet The FDA has alerted the public about interim safety results from an ongoing clinical trial that found an increase in leg and foot amputations, mostly affecting the toes, in patients treated with the diabetes medication canagliflozin (Invokana, Invokamet). The agency has not determined whether canagliflozin increases the … Read more

Politics and the upcoming presidential election may very well doom any major patients-rights legislation this year. At press time, a House bill was stuck in a committee meat grinder. The Senate, without a single Democratic vote, passed a Republican-sponsored bill that President Clinton vowed to veto and Vice President Al Gore promised to use against … 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

Times have changed since the double-digit managed care premium increases of the early 1990s. With 85 percent of the work force in some kind of managed care, employers are no longer pussyfooting around health plans, but instead often dictate benefits to be offered and brutally negotiate premiums. Drastic premium hikes began to be heard as … Read more

Photodynamic therapy employs photosensitizer drugs which can be triggered by anxiety and are subsequently able to socialize with oxygen or different neurological and cell elements to excite a photodynamic reaction frequently causing damage or necrosis to the penile tissues. This treatment effect does occur in most of stem cells which are vulnerable to a source … Read more

Loneliness and social isolation in Elderly adults are serious People Health risks impacting a substantial amount of people who are in america and putting them at an increased risk for dementia as well as other acute health ailments. A brand new reportexternal icon From the National Academies of Sciences, Engineering, and Medicine highlights that more … Read more

BY JOHN A. MARCILLE A lot can happen in a short time. As I write this, President Clinton has just delivered his State of the Union address. A White House summary of his health care proposals is encouraging: putting the strongarm on tobacco companies to shield youngsters from being recruited into the ranks of smokers, … Read more

Weiss Ratings reports that the nation’s HMOs lost a collective $187 million during 1999, despite the positive performance of most of the country’s largest managed care organizations. Chairman Martin Weiss says the disparity between smaller and larger plans is growing — an observation that supports the critical-mass theory that is driving the current round of … Read more

Facilities struggle to find sufficient staff and revenue Approximately 500,000 women give birth each year in rural hospitals, and yet access to labor and delivery units has been declining, according to a report from Kaiser Health News. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that … Read more

In-person and Internet group programs such as the Stanford model are now available to millions, and research indicates that they work Carol Milano It’s an American epidemic — 70 percent of all U.S. deaths are related to a chronic disease. Half the adults here endure at least two ever-present illnesses, according to the National Council … Read more

It’s been a trend for several years: The demand for primary care physicians is accelerating. PCPs are family practice physicians, internists, and pediatricians. This is a “continued and sustained realignment of the physician recruiting market,” according to a recent report issued by Merritt Hawkins & Associates, a physician staffing company. The report says that the … Read more

Enrollment in national HMOs operating in two or more states grew by 14.6 percent, while the number of such companies dropped by 17.4 percent over the last five years, says InterStudy Publications. It’s a sign of mergers, acquisitions, and consolidations in the industry…. Pharmaceutical companies employ 81 percent more people in their marketing departments than … Read more

Prospective Payment System May Encourage Readmissions Hospitals incentivized to release patients too early, study suggests Better coordination between hospitals and post-acute care facilities could reduce patient readmission to hospitals and mortality rates, according to a new study of risk factors conducted by researchers at the University of Colorado’s Anschutz School of Medicine. In a review … Read more

Measures fail to account for socioeconomic status and complex chronic conditions In response to concerns about incomplete and misleading data, 60 senators have sent a letter to the Centers for Medicare and Medicaid Services (CMS) requesting that the agency delay releasing overall star ratings for hospital quality on April 21. In their letter to acting … Read more

Assay looks for apolipoprotein gene variation Researchers have reported the results from a new blood test to help identify which patients are at an elevated risk of Alzheimer’s disease (AD). The findings, presented at the 68th American Association for Clinical Chemistry (AACC) Annual Scientific Meeting & Clinical Lab Expo in Philadelphia, showed that the biochip test, … Read more

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

John A. Marcille The philosopher G.K. Chesterton, writing at the turn of the century (last century, not this one) said, “The whole difference between construction and creation is exactly this: A thing constructed can only be loved after it is constructed; but a thing created is loved before it exists.” Our cover story on IPAs seems to … Read more

Emphasizing the ‘Care’ In Managed Care Generally speaking, if you have 100 physicians who are practicing clinicians, you’re going to have a few whom you would call physician leaders … who have a sense that they have some responsibility to something larger than their own practice.” Though he was talking about the qualities that make … Read more

Nine Pioneer ACOs have dropped out of the elite program but there are true believers among the survivors Peter Wehrwein Venturing into uncharted territory is never easy, so it isn’t really surprising that 9 of the 32 (which works out to 28%) organizations participating in Medicare’s Pioneer Accountable Care Organization (ACO) decided to drop out … Read more

n 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

A medical group I know is positioning itself for capitation. Its members have no experience with capitation payment, but, from what they have heard, the idea is to avoid rewarding a physician for doing a lot of work, since the payment to a practice is independent of what services are actually rendered each month. The … Read more

They are cousinly acronyms, ACO and the ACA. And there’s no question that the 2010 health care reform law was a major boost to ACOs, which, in a nutshell, labor behind the scenes to put health care on a value-based footing while payment dollars are still largely claims-based and flow through fee-for-service channels. So if … Read more

Politicians on both sides of the aisle are considering this as a way of fixing the system. What might it mean for health plans? Martin Sipkoff Contributing Editor Conservatives and liberals agree on very little, of course, but a consensus is emerging at both ends of the political spectrum that the American health care system … Read more

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

Surveys say a lot about quality and are continuously conducted by HMOs and accrediting bodies. The authors suggest medical groups follow suit. Surveys say a lot about quality and are continuously conducted by HMOs and accrediting bodies. The authors suggest medical groups follow suit. “Why measure satisfaction when the health plans we contract with already … Read more

Passing a physician negotiation bill is one thing. Implementing it is another. After months of public comment, Texas Attorney General John Cornyn and the Texas Medical Association finally seem satisfied that rules that took effect June 6 can make the state’s unique physician negotiation law work the way that it’s supposed to. Under federal antitrust … Read more

Gauging and rewarding good work in health care is a noble goal with potentially negative consequences 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 by physicians … Read more

A bill before Congress would give analysts a powerful tool for sifting through Medicare data on the performance of hospitals and physicians For managed care organizations, there’s always been something of a disconnect between members taking more of a hands-on approach to their care and the tools that they actually are given to compare cost … Read more

At the organizational level, Lots of the immediate Advantages of ACO Conversion are available in fiscal form. This is simply not inherently negative; physicians will need to be focused on their financing and so they need to especially at this era, be dedicated to providing care without wasting money — that the hospital or the … Read more

Requiring some patients with chronic conditions to try and fail multiple medications leads to complications and drives up costs, say many physicians. Insurers answer that the trial-and-error approach can be an important way to rein in costs. Step therapy can sometimes be a step backward. For instance, take the case of Eitan Kling-Levine, whose gastroenterologist … Read more

More than a year after the passage of the Accountable Care Act (ACA), employers have seen an average increase in enrollment of their employees in health plans of around 2 percent, probably because the act extended eligibility for coverage of employees’ children up to age 26. That number is going to grow by another 2 … Read more

ABSTRACT Purpose: Insomnia is a burdensome, commonly comorbid condition. How patients value various aspects of the safety and efficacy of available drugs has not been studied. The aim of the present study was to quantify patient-rated utility by studying willingness to pay (WTP) for attributes of symptom relief via a discrete choice experiment (DCE). Methodology: … Read more

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

Full text available in PDF ABSTRACT This paper has undergone peer review by appropriate members of Managed Care’s Editorial Advisory Board. Purpose: To test the hypothesis that a health maintenance organization (HMO) consumer’s satisfaction depends on the way his or her health plan compensates practitioners. Design: Consumer Assessment of Health Plans (CAHPS) survey data from 1999 and … Read more

“The doctor can see you this afternoon” may become the typical response when a patient calls for a same-day office visit. California leads the way. Cindy Ehnes knows firsthand how frustrating it can be when you are trying to arrange medical care for a family member but can’t even get an appointment with a physician. … Read more

CHIP (the Children’s Health Insurance Program) continues to grow by leaps and bounds. The Centers for Medicare and Medicaid Services reports that about 4.6 million children in the U.S. received coverage through CHIP in fiscal year 2001. That’s an increase of 38 percent from fiscal year 2000, which CMS ascribes mostly to state coverage expansions, … Read more

BristolMyers Squibb today announced that the U.S. Food and Drug Administration has accepted its New Drug Application for both CC-486, an investigational oral hypomethylating agent, for the care treatment of older patients with acute myeloid leukemia, that achieved complete remission or CR with in complete blood count healing, after induction therapy without augmentation therapy, and … Read more

Individuals who turn 65 after 20-19 wont be allowed to select Medigap supplement Strategy F, typically the very common supplemental plan which helps retirees pay for health costs that Medicare will not cover. Retirees in Plan F year’s end is going to be permitted to keep. Nearly 60 percent of those 14 million people who’ve … Read more

Which specialties’ single-specialty groups depend most heavily on HMOs for their revenue? According to the Medical Group Management Association, it’s not necessarily the primary care fields ostensibly prized in managed care for their “gatekeeping” role. In two sets of data–one gathered for a survey and the other culled from the association’s membership information–pediatrics and obstetrics/gynecology … Read more

In a world of new access models and price-conscious consumers, the traditional route of patients making appointments to see doctors is being squeezed. These days, consumers are really only interested in schlepping to see a physician when faced with more complex needs. From the physician perspective, this creates a dilemma: While the mix of patients … Read more

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

Medical tourism is flourishing, and folks from all over the globe are very used to traveling over seas for healthcare in yet another nation . Approximately 8 million patients every year. Much of times it boils to Procedures being considerably more expensive overseas, or perhaps maybe not having the ability to seek out the ideal … Read more

Jeffrey Wasserman, Ph.D. The Medstat Group, Santa Barbara, Calif Gifford Boyce-Smith, M.D. Blue Shield of California, San Francisco David S. P. Hopkins, Ph.D. Pacific Business Group on Health, San Francisco Vernon Schabert, Ph.D. The Medstat Group, Santa Barbara, Calif Mayer B. Davidson, M.D. King-Drew Medical Center, Los Angeles Ronald J. Ozminkowski, Ph.D. The Medstat Group, … Read more

In what may be the largest known attempt to gauge quality of care in fee-for-service medicine, a Health Care Financing Administration study has found dramatic variance in treatment of Medicare enrollees for six medical conditions. About 85 percent of the 39 million Medicare beneficiaries are in the fee-for-service program. For purposes of its study, HCFA … Read more

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

The Impact of Molecular Diagnostics on Treatment Pathways, Outcomes, and Cost Adjuvant chemotherapy can improve survival in patients with early-stage breast cancer or colorectal cancer who have undergone surgical resection, but the benefit from this treatment is not universal. A distinguished panel of experts addresses the advance in molecular diagnostic testing and its impact on … 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

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

While developing drugs with corresponding tests may mean lower costs to insurers, it poses significant challenges to the approval process Narrowly targeted medications designed for a specific subpopulation or variant of a disease are game changers in medication therapy. They offer great potential for success in comparison to the hit-or-miss approach where physicians prescribe what … Read more

Changing the way doctors are paid could save over $1 trillion in health care costs, but physicians can’t do it on their own. One of the ways health insurers can help is by joining together to facilitate payment reform, says a study by UnitedHealth Group. “The stronger financial incentives stemming from a multipayer initiative are … Read more

Multiple cost cutting strategies zero in on every aspect of physician remuneration After toying with different ways of controlling rising expenditures for imaging services, such as stressing appropriateness criteria, Medicare is tackling the problem head on by whacking payment rates for services provided in physicians’ offices and in freestanding facilities. In 2009, it cut payments … Read more

In the beginning, about three or four years ago, specialty drugs were primarily used to treat rare genetic conditions such as Gaucher’s disease or diseases such as multiple sclerosis. However, they are being used increasingly to control chronic illnesses, which accounts in part for the increased demand. Although less than 3 percent of people are … Read more

The Disease Management Purchasing Consortium & Advisory Council tracks the growth and success of the industry, based on first-hand information from the roughly 70 percent of all purchases of DM programs that go through the consortium, and from information gleaned about the other 30 percent. The numbers the organization has gathered suggest that the $340 … Read more

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

Survey results demonstrate just how important a topic universal health care and coverage is to the majority of Americans. “The Affordability Crisis in U.S. Health Care: Findings From the Commonwealth Fund Biennial Health Insurance Survey” reports that more than 3 out of 5 adults (62 percent) say they would be willing to give up the … Read more

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

Study assessed trends of resistant P. aeruginosa infection   Highly drug-resistant infections are on the rise among U.S. children, reports a new study published in the Journal of the Pediatric Infectious Diseases Society. Researchers found increasing rates of antibiotic resistance among samples of Pseudomonas aeruginosa, an important type of bacteria, collected from pediatric patients nationwide over the … Read more

John A. Marcille Thomas Jefferson said, “Were it left to me to decide whether we should have a government without newspapers, or newspapers without a government, I should not hesitate a moment to prefer the latter.” Of course, Jefferson was not in power when he wrote this in a letter to Edward Carrington in 1787. … Read more

Learning these lessons from the Veterans Health Administration, the nation’s largest integrated system, leads to organizational success To have a meaningful discussion on improving health care delivery, one must first understand both how the individual components of health care systems function and how they interrelate. In my view, too much of health care today is … Read more

Health Plans Need to Work Beyond Their Comfort Zones John Marcille There once was a time when doctors made house calls. Now, some are making calls on the homeless. Our cover story looks at some of the social determinants of health and begins with a decision to send a taxi to Grand Central Terminal in New York … Read more

January Measurement and rating An in-depth look at quality measurement of providers and health plans Also: Spotlight on real-world evidence February Sexual health STDs, coverage of treatment of erectile dysfunction, and other issues at the crossroad of sexual health and managed care March Biosimilars Also: Update on generics April Telemedicine May Cancer Also: Spotlight on … Read more

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

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

Let’s recap the action so far. The brouhaha over vetoes, shutdowns and the rollback of the Great Society actually revolves around three related issues: agency appropriations, the debt-limit extension and the reconciliation bill controlling entitlements and taxes. Republicans, trying to link the three, hope to force the President to cut entitlements to the max and/or … Read more

The growth in Medicare Advantage (MA) enrollment is coming both from people switching out of traditional Medicare and from beneficiaries new to Medicare, according to a study published in the January 2015 issue of Health Affairs. In 2011, 52% of new MA enrollees switched out traditional Medicare to join the plans and 48% were newcomers … Read more

A California Medical Association examination of HMOs’ expenditure data found that Health Plan of the Redwoods and Kaiser Permanente Northern California spent 96.5 cents of each premium dollar on care in fiscal 1998 — highest in the state. Both lost money; HPR and Kaiser, respectively, spent 11.7 and 3.6 cents on administration…. HMO premiums in … Read more

2018 Media Kit 2017 Media Kit 2018 Editorial Calendar 2017 Editorial Calendar BPA Statement Issue Space Commitment Ad Materials January 12/1 12/5 February 1/2 1/3 March 2/1 2/3 April 3/1 3/1 May 4/2 4/4 June 5/1 5/3 July 6/1 6/6 August 7/2 7/5 September 8/1 8/3 October 9/4 9/6 November 10/1 10/4 December 11/1 11/2

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

Primary Care as a Platform for Value Quantifying the worth of primary care and its delivery are essential for raising its profile. New data and payment incentives may push us closer. Nurse Practitioners Can’t Do What Primary Care Docs Can Do Nurse practitioners are wonderful, but they’re not doctors. The Slow Reveal Rebates have created pay-to-play … Read more

Converging forces are an economic train wreck waiting to happen. Avoiding a disaster requires an understanding of the interconnection of health care’s stakeholders and the global consequences of their actions. Mick L. Diede, FSA, MAAA Richard Liliedahl, MD The cost of our health care system is spinning out of control and no one is applying … Read more

Marker Magic Predictive biomarkers are revamping drug development and breathing new life into old and failed drugs. But this re-thinking of what works, in who, and why raises questions about cost and accessibility. Precision may be pricy. Within our lifetimes, we may look back at chemotherapy and group it with insulin shock therapy, electric baths, … Read more

With the nation’s economy in recession, it probably comes as little surprise that many companies are scaling back executive bonuses for year-2001 performance. However, if health care bonus packages are any indication, then the industry itself would seem to be more immune to the effects of the economy than most other businesses. A survey of … Read more

Joyce Ochs In this age of multi-tasking, we all wear several organizational hats: Managers act as their own secretaries, caregivers are administrators, receptionists have become health insurance experts, and everyone is involved in telecommunications in some way. Now, many of us have added yet another hat: Web content creator. Like e-mail, the Internet has grown … Read more

The memory tape of the golden oldie from Lovin’ Spoonful was playing in my head before watching Dr. Eric Topol’s interview with Dr. Paul Offit about his recently published book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine The book tackles with rigor and vigor the lack of evidence for assertions and testimonials made … Read more

Risk adjustment is part of the reform package, but other countries have had problems with implementation Richard Mark Kirkner MANAGED CARE April 2010. ©MediMedia USA Risk adjustment is part of the reform package, but other countries have had problems with implementation Richard Mark Kirkner It may have been pure coincidence that as congressional debate on the massive … Read more

Our last two columns discussed ways physicians may share information among themselves and with purchasers without running afoul of antitrust law and other legal rules. This month we explore how to keep shared information confidential. The attorney-client privilege protects certain communications between an attorney and his or her clients. When it is in place, no … Read more

Steep discount programs encourage health plans to reduce, or even eliminate, copayments Martin Sipkoff Price wars involving generic drugs are widespread, affecting insurers, retail outlets, pharmacies, and consumers. Although consumer and insurer attitudes about the value of generics have become increasingly positive in the last couple of decades, the pricing of generics was never truly … Read more

Tetrabenazine inhibits the transport of a molecule called vesicular monoamine transporter type 2 or VMAT2 Thomas Morrow, MD Huntington’s disease (HD), named for George Huntington, MD, who lived from 1850 until 1916, is a neurodegenerative disease. It is an autosomal dominant disease and results from a defect of the Huntingtin gene located on chromosome 4, … Read more

MANAGED CARE June 2005. ©MediMedia USA Despite a mandate to adopt utilization management programs and make patients share costs, health plans are still lining up to participate in Medicare Part D. Martin Sipkoff The formulary requirements for Medicare’s voluntary prescription drug benefit are designed to meet the needs of a very specific population: people age 65 and … Read more

On a per-capita basis, prescription drug use in the U.S. is generally highest in the South and Midwest, and lowest in four states with high managed care penetration — California, Massachusetts, Colorado, and New York. These per-member, per-year utilization averages are based on an analysis by Express Scripts, the pharmacy benefit manager, of its commercial … Read more

The top 10 health plans were announced by U.S. News & World Report and the NCQA. The report identified the top commercial, Medicare, and Medicaid plans. Coming in at number 1 again this year among commercial plans was Harvard Pilgrim Health Care of Maine and Massachusetts, with Tufts Associated Health Maintenance Organization, Harvard Pilgrim Health … Read more

Pharmacy Benefit Management in the New World of ACOs Opinions differ on how much and how quickly its role will change, but surely pharmacy can be important in reducing big-ticket episodes of care   Many factors are involved, not the least of which is the loss of patent protection for blockbusters like Lipitor and Plavix, … Read more

Urgent care is a booming part of American health care, but the market may be saturated in several places. Chicago, New York City, Phoenix, and Scottsdale, Ariz., are among the cities where the urgent care market is overbuilt, says Clifford Braff, managing director of the Braff Group, a Chicago brokerage company that represents sellers of … Read more

“We’re thankful to the healthcare providers and their teams that are on front lines combating COVID-19,” stated UnitedHealth Group Chief Executive Officer David S. Wichmann. “The action we’re taking now will provide almost $2 billion accelerated obligations and financial aid therefore that our maintenance provider spouses can concentrate on delivering care.” UnitedHealth Group’s movement to … Read more

Senior Editor Mike Dalzell, author of this month’s cover story on the degree to which so-called “report cards” are being taken seriously, has a daughter in primary school. So does Frank Diamond, also a senior editor. They know about report cards. “When my six-year-old daughter recently brought home her first real report card,” Frank told … Read more

While much of the news about clinical breakthroughs this summer came out of the American Society of Clinical Oncology annual meeting (below), biotechs focused on immunomodulatory and rare diseases were busy moving their discoveries closer to market. In the immunomodulatory area, some players are tossing out only enough information to pacify investors. Novartis says secukinumab, … Read more

Medicaid Overhaul Includes an MLR Rule A 653-page rule handed down yesterday by CMS definitely represents one giant step for Medicaid managed care, and a step taken (for the most part) in the right direction, according to one industry insider. Jeff Myers, president and CEO of the Medicaid Health Plans of America (MHPA), told us last week to expect … Read more

Think of P4O as P4P with its eyes on the prize. Unfortunately, even ordinary P4P is not yet widespread. For many years, managed care plans have used pay-for-performance programs to reward hospitals, physicians, and other providers for following guidelines and improving care processes, but few use P4P to improve clinical outcomes directly. Health plans report … Read more

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

With 2010 well under way, Medicare beneficiaries participating in Part D plans face increasing drug prices for which they will have to pay 100 percent of total drug costs after their spending exceeds the initial coverage limit, according to a new report from the Kaiser Family Foundation. It should be noted, though, that the new … Read more

John S. Lloyd, M.B.A., M.S.P.H. Mary Frances Lyons, M.D. Many find that the risks are worth the rewards in moving from the examination room to the boardroom. As executive search consultants in the health care industry, we often hear from physicians who are considering career changes. Their desire is to move from working as a … Read more

Paying for coordinating care and for packages of services — bundling and episodes of care — may be the best bet for a modification of the unfettered fee-for-service system Tom Reinke In a March editorial in the New England Journal of Medicine, Karen Davis, PhD, president of the Commonwealth Fund, called for basic and timely … Read more

Pay-for-performance programs are gaining in prevalence — nowhere more so than among HMOs. More than half of 252 HMOs surveyed said they implement P4P programs in contracts with physicians and hospitals. Of the 126 HMOs with P4P programs, nearly 90 percent had programs for physicians and 38 percent had programs for hospitals, according to the … Read more

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

Health plan enrollees who take their complaints about coverage issues to an independent reviewer have a good chance of getting HMO decisions overturned — but very few people take advantage of this system. One expert says that this is an indication that a Patients’ Bill of Rights might not raise insurance premiums as much as … Read more

Re-underwriting would be prohibited under a bill introduced in the House and Senate on Oct. 16. Under the legislation, insurers would not be allowed to increase or reclassify premiums “based on a health-status-related factor,” says Sen. Bob Graham, one of the sponsors…. Health benefits for part-time workers were the focus of a labor dispute between … Read more

Researchers at the Icahn School of Medicine at Mount Sinai say that tiny doses of a cancer drug may stop the uncontrollable immune response to infection that leads to sepsis and kills up to 500,000 people a year in the U.S. The new drug treatment may also benefit millions of people worldwide who are affected … Read more

Quantifying the worth of primary care and its delivery are essential for raising its profile. New data and payment incentives may push us closer. David M. Levine, MD, tells a story that pretty much captures the value that policy makers have placed on primary care in America. In essence, says Levine—a clinical investigator in the … Read more

The system’s effect on the private sector has actually been underestimated. Medicare price changes often lead to amplified swings on the private side. Last summer, as physicians around the country were marshaling their forces in what has become an annual campaign to override the deep cuts to physician rates required by the Medicare budget, the … Read more

Thanks for your interest in joining our mailing list(s). Please complete the information below and click Sign Up. Email Address First Name Last Name Job Title Company Email Lists Managed Care newsletter Managed Care table of contents PTCommunity news By submitting this form, you are granting: MMMM Group LLC, an ICON plc Company, 19 West … Read more

In order to get the most out of EHRs, providers need to think outside the box—the box in this case being CMS’s meaningful use requirements, according to wisdom contained in a PwC survey. The three stages of CMS’s meaningful use program dangle incentives to encourage hospitals and other health care providers to improve their electronic … Read more

MANAGED CARE Taking On Too Much This issue of Managed Care was billed as being about Medicaid managed care and vulnerable populations. But as grumpy editors often say, that’s a topic not a story. And it didn’t take us very long to discover that the story was social determinants of health. Lola Butcher, a regular contributor … Read more

Leaders of seven of the largest drug companies to appear before the Senate Finance Committee. Leaders of seven of the largest drug companies to appear before the Senate Finance Committee. Fox-henhouse concerns will shadow the proceedings today as leaders of seven of the largest drugmakers give an accounting to the Senate Finance Committee about why … Read more

Palliative care is a particular sort of health care. It is supposed to Two brand new NIH-funded studies contribute to growing evidence that palliative care may improve standard of living. Palliative care functions Together with other remedies to facilitate bodily Outward symptoms and give social and emotional aid to caregivers and patients. It is different … Read more

John A. Marcille Confrontation and cooperation: Both have their place. Senior editor Frank Diamond’s cover story on the relationship between hospitals and health plans highlights the confrontational or competitive end of the spectrum. In the aftermath of the Balanced Budget Act of 1997, Washington’s inexpertly crafted milk-Medicare measure, the relationship between HMOs and hospitals has become downright … Read more

Schultz, who had been CEO and presidentsubmitted his resignation Effective instantly for that which he explained has been demonstrating behavior he realized was inconsistent with his own worth and those of the provider. Unfortunately I recently exhibited behaviour inconsistent with my own core values and also the organization’s core values and code of behavior. Throughout … Read more

In a dramatic attempt to keep a lid on health care premiums, the California Public Employees’ Retirement System threw out every bid it received from health plans competing for a chunk of its business in 2002. CalPERS says it was offered premium hikes ranging from 5 to 40 percent. Plans were invited to re-bid, though … Read more

As the healthcare industry continues the shift toward value-based medicine, Medicaid plans and providers have two clear avenues to pursue in demonstrating success in managed care and population health that can improve their HEDIS scores: In the near term, closing gaps in screening procedures to improve adherence. Over the long term, working to change the health behaviors … Read more

The trend of smaller and more specialized health plan design is likely to continue in 2016 as insurers and employers look for ways to build networks that control costs without damaging quality. Exchange plans for 2016 already reflect this. An analysis by Avalere found a 31% drop in the percentage of exchange plans offering PPO … Read more

Its new branding campaign may be a ‘right mistake’ “We made too many wrong mistakes,” is one of the many “duh” quips attributed to Yogi Berra. But it could also be an insightful analysis of the many attempts of pharmacy benefit managers (PBMs) to connect with patients. “Historically PBMs have been invisible to consumers,” says … Read more

Opinion leaders say Congress should also act to improve quality and safety, and ensure Medicare solvency. Covering the uninsured should be Congress’s top health care priority over the next five years, say 87 percent of health care experts polled recently. Other top priorities are improving quality and safety of care (including increased use of information … Read more

Next year there will be a total of 1,109 prescription drug plans (PDPs) offered nationwide, down nearly one third from 1,576 in 2010. The reduction can be attributed to recent regulations issued by the Centers for Medicare & Medicaid Services, which sought to eliminate duplicative plan offerings and plans with low enrollment. At the peak … Read more

Findings of this retrospective database study further emphasize the importance of effectively managing the side effects of opioid pain therapy and achieving optimum clinical and economic outcomes, thus improving the quality of care Full text in PDF Abstract Purpose: The main objective of this study was to compare the opioid use patterns, resource utilization, and costs … Read more

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

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

Insurers have traditionally focused their attention on savings through therapeutic equivalents, which contain the same active ingredients, strength, and dosage form as the original brand-name drug. But, according to an article published in the British Journal of Generic Medicines titled “Maximising Generic Utilization: The Power of Pharmacy Benefit Management,” more insurers are focusing their attention … Read more

Premiums dropped 0.7 per cent last year across the land, a survey of 466 HMOs shows. The annual report by the consulting firm Milliman & Robertson indicates that over the year beginning July 1, 1995, the weighted average premiumweighted average premium for HMO enrollees declined from $150.72 to $149.67 a month. Co-author David Ogden said … Read more

 Download PDF Abstract Background: The high rate of 30-day hospital readmissions among Medicare patients highlights a glaring care gap in the treatment of elderly patients. To improve quality of care, increase patient safety, and reduce the associated costs of these readmissions, transitional care programs are being implemented to facilitate continuity of care from hospital to … Read more

Gallup survey shows uninsured rate up from 10.9% in last half of 2016 The percentage of U.S. adults without health insurance grew in the second quarter of 2017 to 11.7%, up from 11.3% in the first quarter, according to a Gallup survey released July 10. The uninsured rate, measured by Gallup and Sharecare since 2008, … Read more

Some of the biggest insurers in the country scramble to make sense of a field that will change treatment techniques forever As a certified genetic counselor, Heather Shappell learned early on how to calculate an individual’s hereditary risk of cancer and how to adjust that person’s medical care to account for it. If someone comes … Read more

A clearinghouse was created that stores details about malpractice suits and disciplinary actions. So how come HMOs don’t use it? It all seemed simple 15 years ago. A young congressman from Oregon, Ron Wyden, came up with a plan to track bad doctors. Wyden was troubled by reports that physicians responsible for harming patients could … Read more

John A. Marcille We know that this may be the most inflammatory issue that we have ever produced, between “alternative” medicine on the one hand and physician unions on the other. Our purpose is neither to upset nor to coddle you. We just want to keep you informed. Still, as they say, a little knowledge … Read more

  In many ways, this was a banner year for biosimilars. It looks like 2017 will be a different story, as two critical issues cast a shadow on their future. This year, biosimilar makers went right into the heart of the lucrative biologics market. The FDA approved Amjevita (originator, adalimumab [Humira]), Inflectra (originator, infliximab [Remicade]), … Read more

Health reimbursement arrangements are back and could mean health coverage for employees of small businesses. Skeptics believe few businesses will offer HRAs. For four years, businesses that wanted to reimburse employees for their health insurance premiums rather than buying their coverage for them were told that was no longer allowed under the ACA. But the … Read more

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

You could never really describe the health insurance industry as sleepy. Born during World War II to address a labor shortage, employer-sponsored coverage may have, at times, been the butt of jokes similar to those aimed at accounting and banking. However, Eisenhower’s no longer in office and as Virgil said, “Health is the greatest wealth.” … Read more

Progress costs money, industry finds Large health systems and hospital operators are reporting sliding profits, revenue, and income because of value-based care, according to an article posted on the HealthLeaders Media website. A turnaround is expected, however, once the industry more fully adopts the value-based model. Kaiser Foundation Hospitals and its subsidiaries, for example, have shown a … Read more

When cancer strikes, people want the best treatment. Too often, however, patients equate cost with quality, thinking that pricier treatments offer the best chance of killing the demon, or at least holding it at bay for a few years until reinforcements (breakthrough technologies and treatments) arrive. Value-based care isn’t on the minds of many people … Read more

Despite a lack of evidence to show a return on investment, health and wellness programs in the workplace are now common, according to the Center for Studying Health System Change. For more details about how employers are encouraging employees to sign up or continue with their wellness program, see our Outlook column on page 56. … Read more

By the time a market has entered what I’ve called Phase III of the transition to managed competition, it is clear that there is excess hospital capacity. That leads to the aggressive formation of physician-hospital organizations. But there are four dangers physicians should consider if they’re thinking of joining a PHO. First, many of the … Read more

As a fourth-year clinical understudy and a warning senior member at the Perelman Institute of Medication at the College of Pennsylvania, we have seen burnout and sorrow flourish during clinical school. Inquisitive about how they may be influenced by monetary pressing factors, we overviewed clinical understudies at US News and World Report’s main 10 positioned … Read more

The author reviews a number of their newest doctor self-referral (Star K ) rule’s primary implications for medical set reparation plans. In Stage II of the Stark law, the Centers for Medicare & Medicaid Services described certain provisions and others maybe not coped with in Stage I. The fluctuations have major, broadly speaking positive consequences … Read more

The Most Satisfying HMO: What It’s Doing Right Capital District Physician’s Health Plan has shown over the past two years that it’s a national champ at satisfying members. But it must struggle to keep doctors happy while meeting ever-tougher competition. Getting ACE Inhibitors Into the Right Hands We know that ACE inhibitors are a front-line … Read more

Changing the process and mindset of health care professionals was the key to reducing emergency department overcrowding Joseph R. Twanmoh, MD, FACEP Assistant Professor of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Md. Gail P. Cunningham, MD, FACEP Head, Department of Emergency Medicine, St. Joseph Medical Center, Towson, Md. Full text in PDF … Read more

Advances in treatment have helped patients manage chronic pain with pharmaceutical pain relievers, but some drugs — particularly opioids — carry the risk of dependence. Opioid dependence is a medical condition, and it can be treated, but employers may not know about all the treatments that are now available, or that they are covered by … Read more

Sulfonylureas are cost-effective and also may be the only oral agents that inhibit processes inducing hyperglycemia by improving insulin secretion and insulin resistance. New long-acting agents hold even greater promise. Udaya M. Kabadi, MD University of Iowa Hospitals and Clinics Full text of this article is available in PDF. Abstract Diabetes exacts an enormous toll … Read more

ERAS protocols are worth the investment, Johns Hopkins team says The cost of implementing a new quality improvement program that helps colorectal surgery patients recover faster is more than offset by savings from their reduced lengths of stay at hospitals of any size, according to a study from Johns Hopkins Medical Institutions in Baltimore. The … Read more

Name Last modified Size Description Parent Directory 28-Aug-2000 11:10 – 9808.news_whatstheri..> 29-May-2000 11:52 1k 9808.news_newdrugs.s..> 29-May-2000 11:52 1k 9808.washington_gord..> 29-May-2000 11:54 1k 9808.washington_tele..> 29-May-2000 11:54 1k 9808.news_wheres.shtml 29-May-2000 11:52 1k 9808.news_headlines…> 29-May-2000 11:52 1k 9808.states_kentucky..> 29-May-2000 11:53 1k 9808.washington_some..> 29-May-2000 11:54 1k 9808.compmon.shtml 29-May-2000 11:52 2k 9808.washington_medp..> 29-May-2000 11:54 2k 9808.states_texas.shtml 29-May-2000 11:53 2k 9808.washington_take..> … Read more

Name Last modified Size Description Parent Directory 30-Sep-2000 10:40 – 9808.news_whatstheri..> 29-May-2000 11:52 1k 9808.news_newdrugs.s..> 29-May-2000 11:52 1k 9808.washington_gord..> 29-May-2000 11:54 1k 9808.washington_tele..> 29-May-2000 11:54 1k 9808.news_wheres.shtml 29-May-2000 11:52 1k 9808.news_headlines…> 29-May-2000 11:52 1k 9808.states_kentucky..> 29-May-2000 11:53 1k 9808.washington_some..> 29-May-2000 11:54 1k 9808.compmon.shtml 29-May-2000 11:52 2k 9808.washington_medp..> 29-May-2000 11:54 2k 9808.states_texas.shtml 29-May-2000 11:53 2k 9808.washington_take..> … Read more

BY JOHN LA PUMA, M.D. Autonomy has transformed medical ethics in just half a century. Gone is beneficence-based medical ethics in which the doctor knows and acts for the patient’s good, and patients do their best to get better. Earlier in this century, our country had more of a sense of community, togetherness and scarcity. … Read more

PBM reports show spend grew by 2% in 2018 Adam J. Fein, the drug price and supply chain expert consultant, said this morning that his review of 2018 reports by four large PBMs shows that drug spending by those PBMs grew by 2% last year. “Once again we find that drug spending is not skyrocketing–contrary to what you … Read more

Preventive Maintenance has evolved to an Essential Quality of Medicaid as it Gives states the power to enhance control policy healthcare, and costs, and to present and pursue crucial alterations in care delivery to enhance health insurance and healthcare. From 2017, 70 per cent of Medicaid beneficiaries were enrolled at comprehensive plans provided by managed … Read more

Name Last modified Size Description Parent Directory 30-Dec-2000 15:10 – 9808.compmon.gif 06-Jul-1999 09:03 51k ../../../archiveMC/9808/9808.compmon.pdf 06-Jul-1999 09:03 45k ../../../archiveMC/9808/9808.news_docreport.gif 06-Jul-1999 09:04 37k ../../../archiveMC/9808/9808.news_riskchart.gif 06-Jul-1999 09:04 18k 9808.outlook.gif 06-Jul-1999 09:05 53k ../../../archiveMC/9808/9808.outlook.pdf 06-Jul-1999 09:05 44k 9808.truce_gatechart..> 06-Jul-1999 09:06 16k 9808.washington_thom..> 01-Jan-2001 22:04 2k 9808.washington_tele..> 01-Jan-2001 22:04 1k 9808.washington_take..> 01-Jan-2001 22:04 2k 9808.washington_some..> 01-Jan-2001 22:04 1k 9808.washington_medp..> … Read more

Overlooked in the recent concern over the measles outbreak in the United States is the fact that this is a worldwide problem that requires a worldwide solution, says health care journalist Faye Flam. Writing in Bloomberg, Flam points out that this year Madagascar saw a huge outbreak of the disease that killed 1,200 children. (To put … Read more

Emergency Care Examined PETER WEHRWEIN A yearlong inquiry by Managed Care Emergency Medicine: The Origin Story  ROBERT CALANDRA Air Ambulance Turbulence: Consolidation, Cost Shifting, and Surprise Billing JAN GREENE It is a heroic part of the American health system. Lives are saved, the dire consequences avoided. But the air ambulance industry is consolidating, prices are soaring, … Read more

CMS veteran Marilyn Tavenner oversaw a rocky debut for HealthCare.gov. Now she’s at the helm of AHIP as some major members need to be coaxed back into the fold. Marilyn Tavenner, MHA, was hired as president and CEO of AHIP last July, succeeding longtime predecessor Karen Ignagni. Just weeks before she took the job, UnitedHealth … Read more

Despite the bearish market and sluggish economy, at least one physician class is enjoying comfortable salaries: pediatric subspecialists, including pediatric anesthesiologists, surgeons, cardiologists, and neurologists. Academic hospitals, which tend to offer lower salaries than private hospitals and clinics, are surprised to learn that the $150,000 to $180,000 they initially budget to recruit a pediatric anesthesiologist … Read more

A recent report from the IMS Institute for Healthcare Informatics suggests a continuing shift toward government payers (Medicare and Medicaid) to help beneficiaries pay for prescription medications. Commercial insurance was used to pay for 63 percent of dispensed prescriptions in 2010, according to the report, The Use of Medicines in the United States: Review of … Read more

Conversations about the value of health care treatments have not traditionally included the patient perspective. In the past, value has been measured through cost-effectiveness analyses that weigh the clinical benefits of a treatment against its costs without a consideration of how those benefits align with what patients want from a treatment. Value-assessment efforts often included … Read more

Five vials of calcium EDTA cost $27,000 A decades-old intravenous treatment for lead poisoning has hospitals and poison control centers seeing red after Valeant Pharmaceuticals hiked the price more than 2,700% in a single year, according to a report from STAT News. Valeant acquired the treatment––calcium EDTA––from another company in 2013. Before Valeant took over, a … Read more

Under the recently passed Tax Relief and Health Care Act of 2006 (H.R. 6111), individuals and employers may contribute $2,850 (for an individual) or $5,650 (for a family) to a health savings account (HSA) for 2007, regardless of their health plan’s deductible. In addition, the reform will allow the following: Full HSA contributions for employees … Read more

Companies that make the effort to find out what they are saving with their wellness programs are often pleasantly surprised, says a study by the International Foundation of Employee Benefit Plans. The IFEBP, a not-for-profit group that studies benefit plans, surveyed 447 member organizations, finding that about 1 in 5 analyzes ROI and of them, … Read more

While states are implementing broad policies to control Medicaid costs, outpatient prescription psychiatric drugs are falling into newly created exemptions, according to a recent survey conducted by the Bazelon Center for Mental Health Law. For example, 30 states exclude some or all psychiatric medications from prior authorization policies, and 15 states with preferred drug lists … Read more

Medicare is expected to lead payment reform, but major players in the private sector are banding together to move it along Lola Butcher Contributing Editor MANAGED CARE April 2009. ©MediMedia USA Medicare is expected to lead payment reform, but major players in the private sector are banding together to move it along Lola Butcher Contributing Editor The … Read more

BY NEIL CAESAR, J.D. Effective managed care relationships are forged with the intent that they be long-term arrangements. A managed care contract is rarely worth the effort of careful negotiation if the relationship will not likely last. Consequently, providers and managed care plans must utilize the earliest stages of contract negotiation to assess each other. … Read more

Has the price of increased life expectancy been greater rates of people living with disability? A study published in the Proceedings of the National Academy of Sciences challenges this popular assumption. The share of older people with chronic disabilities fell from 26 percent in 1982 to 20 percent in 1999. The improvement is due to … Read more

Along with traditional systemic therapies, the American Academy of Dermatology recommends four biologic agents as first-line treatment for psoriasis patients who are candidates for systemic therapy. Thomas Morrow, MD Vice President and Medical Director, Matria Healthcare, Atlanta Full text of this article is available in PDF. Psoriasis is one of the most common skin disorders, … Read more

One reason that spending on medications has increased during the last 15 years is that physicians are turning to pharmaceuticals to help patients battle comorbidities, according to a study in Health Affairs. The study relies on data taken from 289,000 patient-encounter records collected by the Centers for Disease Control and Prevention. Not only did visits … Read more

Decellularized vascular grafts will be studied in dialysis patients with ESRD   May 23, 2016 AlloSource, a nonprofit cellular and tissue network, has announced the distribution of investigational bioengineered blood vessels for use in phase 3 clinical studies. The first shipment will be used in a trial investigating the potential of the blood vessels, manufactured … Read more

RED TAPE DEPT. HMOs may be trying harder, but PPOs seem less interested. Then there’s the whole issue of credentialing’s relationship to the licensure process. Frank Diamond Senior Editor Nothing, it seems, upsets health plan officials and physicians more than health care anecdotes. Executives hate stories about HMOs; physicians hate stories about doctors. But there … Read more

Submitted by Neil Minkoff MD on Fri, 2013-02-01 18:07 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 … Read more

Most disease management (DM) programs that address diabetes do a poor job of it, relying on outmoded means of communication that fail to motivate workers, says a survey of companies belonging to the Northeast Business Group on Health (NEBGH). Diabetes is the most targeted condition of nearly half of U.S. companies with 50 employees or … Read more

Best health officials Voiced Increased concern on Monday about the Threat introduced to the USA by the Zika virus, even saying the mosquito which spreads it really is currently contained in roughly 30 countries and thousands and thousands of ailments can emerge in Puerto Rico. At a White House briefingthey stepped up pressure onto the … Read more

Show Us (the U.S.) the Savings Biosimilars are saving money but not in the U.S., where companies have used a variety of stalling tactics. Now Pfizer and others are accusing Johnson & Johnson of withholding rebates to fend off biosimilar competition to Remicade. THOMAS REINKE Bringing Humira (Its Price) Down a Peg The TNF-α blocker is … Read more

Tens of thousands of rural U.S. hospitals trying hard to remain in operation, Health policy choices made in Washington, D.C., that summer can make survival a great deal rougher. As 2010, at 79 rural colleges have shut around the Country, and almost 700 more are in danger of closing. These associations serve a mainly elderly, … Read more

If you’re coping with type two diabetes, then you undoubtedly are not by yourself. One in 10 men and women in the usa has diabetes, based on the CDC. But, despite considerable improvements in diabetes treatment on the previous twenty decades, under half those with diabetes actually reach their target blood glucose target. Inpart, This … Read more

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

MANAGED CARE November 2004. ©MediMedia USA Use of COX-2-selective inhibitors decreased and the use of generic NSAIDs increased as formularies incorporated drug tiers, according to a study in the Archives of Internal Medicine. Enrollees in three-tier plans with arthritis and gastrointestinal comorbidities were significantly less likely to use COX-2-selective inhibitors than were patients in nontiered plans. “Previously … Read more

In reaction to practitioner and patient demand and increasing signs of its importance in looking after the sickest and most vulnerable patients while in america medical care procedure. The incidence of hospital-based PC services has risen by 26% in recent years; 67 percent of most hospitals and more than 90 percent of hospitals with over … Read more

Even the truism which’there Isn’t Any health care with no Work-force’ is acknow- Ledged but listened up on. We’re hurtling toward a international function meltdown in health care as a result of growing and ageing populace that puts greater demands and requirements health just enough period as soon as the ratio of researchers to elderly … 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

The publicity given to the Texas attorney general’s agreement with Aetna overshadowed a more sweeping edict in Arizona regarding financial incentives to physicians. A new state law taking effect this summer forbids plans from offering financial incentives to limit or delay care. The bill also gives members the right to sue health plans found responsible … Read more

Tricare saves itself unnecessary grief by reaching out to beneficiaries who need only call up Frank Diamond Tricare, the military’s health program, launched a blog last year that’s paid dividends from the start. “We’ve had 65,000 visits since last July and nearly 1,000 comments and questions,” says Maj. Gen. Elder Granger, who, until he retired … Read more

When Tim Stezzi and Tim Search launched Managed Care in 1992, the backlash against its eponym was in full swing. Hundreds of bills had been introduced in state legislatures the year before to curb the perceived excesses. Utilization review was being questioned, gatekeeping disparaged.  “It… Q&A; Weighing the Future of Value-based Care: You Need Scale PETER … Read more

JOB NUMBER: HH0726 GRADE: M11 DEPARTMENT: Business Development REPORTS TO: Senior Vice President HFHS – President & Chief Executive Officer HAP Apply via email to [email protected] or online at http://p.rfer.us/HENRYFORDlXqAJA Primary Objectives: Provides executive leadership to meet or exceed revenue requirements and market share expectations consistent with organizational goals and objectives and in accordance with a rolling three-year … Read more

Over the next three years, large and small health plans and PBMs that are currently involved in emerging health information technologies are going to focus on increasing disease management programs and on providing personal digital assistants (such as the Palm) to physicians, according to a report by the Foundation for Managed Care Pharmacy, the educational … Read more

A few years ago some enterprising writer decided to do a story that was so obvious that almost everybody else missed it. Go to a major league baseball game and you’ll see that the baseballs themselves are used and discarded with the frequency usually reserved for tissue paper during flu season. Does a ball have … Read more

But EHR use is a potential obstacle, and beneficiaries may balk at paying for what they once got at no charge Baby step by baby step, CMS seems determined to get away from the perverse incentives —and disincentives—associated with fee-for-service medicine. Medicare’s Chronic Care Management (CCM) payments, intended to encourage greater care coordination, is the … Read more

Politics and the upcoming presidential election may very well doom any major patients-rights legislation this year. At press time, a House bill was stuck in a committee meat grinder. The Senate, without a single Democratic vote, passed a Republican-sponsored bill that President Clinton vowed to veto and Vice President Al Gore promised to use against … Read more

  To place an ad in on this page, please contact Dawn Flook, or by e-mail (link sends e-mail). Cost is $150.00 for 30 days. To place a classified ad in Managed Care magazine (print edition) contact Dawn Flook as above. Pricing depends on frequency and space used. Read Next Gretchen Jacobson Kaiser Family Foundation … Read more

Some powerful business groups charge that association health plans, one of the cornerstones of the Bush administration’s attempt to reform the medical system, would harm those companies that choose not to participate. Also, say opponents, AHPs would lead to expensive federal regulations, unpaid medical bills, and increased marketplace fraud. The U.S. Chamber of Commerce, and … Read more

Paying for coordinating care and for packages of services — bundling and episodes of care — may be the best bet for a modification of the unfettered fee-for-service system Tom Reinke In a March editorial in the New England Journal of Medicine, Karen Davis, PhD, president of the Commonwealth Fund, called for basic and timely … Read more

The National Committee for Quality Assurance has released a draft of its long-awaited PPO accreditation program. NCQA plans to evaluate PPOs on such aspects as access to care, provider credentialing, consumer protections, and oversight of medical groups and others to whom the PPO delegates responsibility for care. Member satisfaction will also be part of NCQA’s … Read more

Forever Young Submitted by Steven Peskin MD on Fri, 2012-09-21 12:05 As a baby boomer moving through middle age into the unspeakable age that follows “middle,” I was encouraged to read an article in the British Medical Journal that states that for seniors and super seniors, healthy behaviors that include regular exercise, not smoking, maintaining a … Read more

MANAGED CARE August 2009. ©MediMedia USA Great issue! Just a note to say “well done” on the May issue. I routinely read [publications in] the cluttered and confused managed care space, and have rarely seen such focus and detail to the primary issues that matter. The Ingenix decision is big [“The Ingenix Aftermath,” page 6], and so … Read more

John A. Marcille Disease management is one of those things that are forever on the verge of something. Year after year, we monitor the ups and downs of this dynamic industry. I say dynamic because no other topic creates such passionate interchange between the editors and writers here, and it is the subject of frequent … Read more

Name Last modified Size Description Parent Directory 11-Jan-2005 13:10 – 0005.qna_eisenberg.html 09-Jun-2003 15:00 17k 0005.pity.html 09-Jun-2003 11:44 26k 0005.conf.html 09-Jun-2003 11:44 8k 0005.broker.html 09-Jun-2003 11:44 17k 0005.compmon.html 09-Apr-2003 23:33 2k 0005.contents.html 09-Apr-2003 23:33 3k 0005.news_fudge.html 09-Apr-2003 23:33 2k 0005.news_arizona.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 09-Apr-2003 23:33 2k 0005.news_texas.html … Read more

The man credited with health care innovation at IBM warns against any overhaul that would make companies disinclined to participate Credited with saving IBM millions of dollars in health care costs through wellness and health management programs, Martin Sepulveda, MD, then accepted the challenge of leading the company’s overall health benefits programs globally. Today, as … Read more

Physicians who want to participate in workers’ compensation programs should recognize that employers are not just buying their expertise in treating illness and injury, though they will surely insist on that expertise. The companies that pay high premiums for workers’ comp insurance want physicians to do their utmost to get their employees back on the … Read more

Having driven generic utilization about as far as possible, plan sponsors are turning to a method of controlling drug costs that had all but disappeared. Aggressive contracting is driving this trend, but that may soon yield to evidence-based evaluation. If this decade has a feeling of deja vu, well, you can be forgiven. A lot … Read more

Oahu is one of the most ever reported at a calendar year, although the tendency is principally credited to elevated testing. That is The speed climbed 5 percent. Boffins stress antibiotic immunity could possibly be one variable. And the syphilis rate climbed 15 percent. Approximately 35,000 cases of their very infectious kinds of this disorder … Read more

The median base salary of family physicians has posted healthy increases of more than 4 percent in the last two years on top of a whopping 13-percent jump in 1995, according to the Hospital and Healthcare Compensation Service. AMA figures sketch out three other facets of family physicians’ current condition: They’re less likely than the … Read more

The promise of managed care has always had a lot to do with what its advocates hoped would be the ability to provide care for populations, not just individuals. This was a radical concept to many people, and still one that is not too easy to explain to people outside the industry. Early commercial HMOs … Read more

LOOKING FORWARD For other articles in the series, see listing at end Now that the hard part — forging quality-measurement systems for HMOs and point-of-service plans — has been done, the next step is to adapt these programs to the rest of the health care industry. Margaret E. O’Kane Twenty years ago, when fee-for-service practice … Read more

Participants that received 4,000 IUs of vitamin D each day saw their cerebral stiffness reduction 10.4 percentage at the four weeks of a latest analysis. In people that obtained 2000 IUs, cerebral stiffness fell two per cent throughout the analysis. One of participants that obtained 600 IUs, arterial stiffness climbed 0.1 percentage nonetheless, individuals that … Read more

The very first company diagnostics were launched at the 1980s as well as at the face of significant first disbelief from medication programmers concerning whether a medication’s market through a diagnostic has been wise. By a first beginning of a couple of oncology medication with accompanying diagnostics, the field has expanded to comprise multiple therapeutic … Read more

NEWS & COMMENTARY Race trumps region when it comes to which people with diabetes might be more at risk of having a leg amputated, according to the latest installment of the Dartmouth Atlas of Health Care Series. The raison d’être of the series is to measure practice variation variation across the country. However, this report … Read more

A state senator who clarifies glucose prices since”outrageous” introduced a foil bill which requires drug makers to document pricing, outlays, and concessions. Other nations may possibly create similar motions, and also the pharmaceutical business is suddenly on border, together with PhRMA and BIO fighting regulations in court. At a country with a enormous bet in … Read more

Synthetic peptide reduces new vertebral and nonvertebral fractures Positive results have been announced from a phase 3 study of self-administered subcutaneous (SC) abaloparatide (Radius Health, Inc.) for the treatment of postmenopausal women with osteoporosis. The study showed that patients treated with daily abaloparatide for 18 months had a significantly greater reduction in the incidence of … 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

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

WHO to meet tomorrow to decide on international public heath emergency declaration Federal officials are closely monitoring an outbreak of a new coronavirus in China that has resulted in more than 200 infections and at least six deaths, according to a report by Reuters this morning. Other news outlets also put the mortality count at six. … Read more

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

Proponents say ISO 9000 standards are a less prescriptive, ponderous and costly way to review hospitals. But are they truly applicable to health care? Proponents say ISO 9000 standards are a less prescriptive, ponderous and costly way to review hospitals. But are they truly applicable to health care? Frank Diamond Senior Editor Nothing sets off … 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

Medical roots run deep in the man who is leading the transformation of medical care delivery at the nation’s largest HMO. Both of Peter Juhn’s parents and a grandfather preceded him in the medical profession. Today, as executive director of Kaiser Permanente’s Care Management Institute in Oakland, Calif., Juhn is responsible for developing systematic approaches … Read more

Operation, nursing, and medical practice, and also the clergy to take into account what directed Kaitlyn, a new medical student, to carry her life on April 1 1, 2013. Drawn from personal adventures, the writers reveal the things that they believe is that a culture of silence under intense pressure that compels athletes and physicians … Read more

Abstract Purpose: To evaluate the effectiveness and costs of linaclotide (Linzess) versus lubiprostone (Amitiza) in the treatment of adult patients with chronic idiopathic constipation (CIC). Design: A decision-tree model using model inputs derived from published literature, linaclotide phase 3 trial data, and a physician survey. Methodology: Measures of treatment efficacy were selected based on comparability between trial data, … Read more

After 10 Years of fighting regulatory approval and People Approval, a biotechnology business has released genetically engineered mosquitoes in to the open atmosphere in the USA for the very first time. The experimentation, established this week at the Florida Keys — on the objections of several regional critics — evaluations a way of controlling inhabitants … Read more

When infusion therapy, for example, is given at home—a less costly setting—both patient comfort and health plans’ bottom lines benefit. But if hospitals buy up all the practices, payers may lose the chance to save. It seems outrageous when you think about it. During a trial in U.S. District Court last year, a consultant for … Read more

Medication safety can be seen as a global concern requiring close collaboration Globalization of drug development and drug marketing has spawned a movement, though small, toward international drug regulation. In a Dec. 15, 2010 interview with the Wall Street Journal, Thomas Lonngren, outgoing head of the European Medicines Agency, which approves drugs in Europe, said … Read more

In a study that confirms what has long been assumed, Medicare HMO enrollees become more likely to drop their carriers when they exceed annual pharmacy-benefit caps. Express Scripts, the pharmacy benefit manager, published its findings in the Journal of the American Medical Association in late November. The link between exhaustion of drug benefits and Medicare … Read more

Changed the way patients go through the ending of life. With more life Spans, there’s already been an escalation in years lived with disability. The clustering of disorders from the last decades of existence is especially At the conclusion of existence, Patients with cardiovascular illness are far more symptomatic, not as inclined To expire in … Read more

Medicaid expansion and Covered California’s $100 million marketing Program Makes the person insurance market workable. This, Though premiums Have risen in the last couple of years (4.2percent in 2015, 4 percent in 2016, 13.3percent in 20 17 ), and also a motion to put in a Singlepayer system will Inflate the Private insurance marketplace.

Exactly why Have healthcare prices skyrocketed in the previous decade? Some have implied that the excellent Recession alone has been the origin, but health cost increase from the depths of this downturn was not quite equal to growth before the downturn. Nor can the Affordable Care Act accept charge, since the downturn began ahead of … Read more

Updated Results Reported From Study of Reolysin in Patients With Pancreatic Cancer Reovirus variant improves overall survival   Oncolytics Biotech has announced updated results from a randomized phase 2 study of Reolysin, a proprietary variant of the reovirus, in combination with carboplatin and paclitaxel in patients with metastatic pancreatic cancer. The study was sponsored by … Read more

The mantra “location, location, location” is getting a lot of play, both in real estate and in the specialty pharmacy arena, according to the 2011 Express Scripts Drug Trend Report. That’s because the PBM’s effort for its members to receive specialty medication in the most cost-effective environments — patient homes and physician offices — demonstrates … Read more

John A. Marcille True, there are more uninsured now than there were seven years ago. True, health care alliances and employer mandates failed to materialize. True, no National Health Board was ever created to monitor the functioning of employer health alliances. Yet, yet… A caption under the photograph of President Clinton on this month’s cover … Read more

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

The Nuka Way One of the four 2011 Malcolm Baldridge National Quality Award winners in health care is Southcentral Foundation, a nonprofit organization established in 1982 to serve Alaska Natives who live in and around Anchorage. The Southcentral Foundation (SCF) describes itself as a Nuka system of care — Nuka being an Alaska native name … Read more

You don’t want to send money down a rat hole, but then again, off-label usage may be just what a patient needs The federal government’s expansion of coverage of off-label drug therapies is putting pressure on private insurers to follow suit, even as government and private payers clamor for physicians to avoid treatments where evidence … Read more

Some of the nation’s best health plans are coming up with creative ways to encourage women to get mammograms. Sharon Baker The importance of breast cancer screening received renewed attention in November after Elizabeth Edwards was diagnosed with the disease and acknowledged that she had not had a mammogram in four years. Edwards, the wife … Read more

FDA Approves Emtricitabine/ Tenofovir (Descovy) for HIV Infection Fixed-dose combo can be paired with range of third agents The FDA has given the green light to Descovy (emtricitabine 200 mg/tenofovir alafenamide 25 mg [F/TAF], Gilead Sciences), a fixed-dose combination for the treatment of human immunodeficiency virus-1 (HIV-1) infection. Descovy is indicated for use in combination … Read more

We’re all over the place, this month. A magazine can be compared to a car that’s assembled by engineers challenged to build something without a blueprint. What emerges will run, often very well, but who knows what it will look like? This month we’re surprised, again, by just how much a many-tentacle thing is managed … Read more

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

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

To get medics on the battle and also physicians in distant or Growing portions of the planet, gaining quick accessibility to the medication necessary to handle patients might be hard. Biopharmaceutical drugs, that can be utilized in a Wide Selection of treatments Containing drugs and vaccines for cancer and diabetes, have been generally generated in … Read more

Vaccines save tens of thousands of lives each year. They’re among the safest & best public health interventions to keep inhabitants healthy whilst attracting numerous societal and financial advantages. Vaccines play an significant function in making sure children, irrespective of where they live, might have a wholesome start to life. Rely upon vaccines and at … Read more

Rebates are generally calculated for a proportion of list prices, and PBMs maintain a share of these blessings that they pay for. Even though this installment gives PBMs the incentive to pay bigger refunds to their medication plan customers, but in addition, it gives them the incentive to boost list price increases so as to … Read more

From the analysis, the researchers tested the hypothesis which K. pneumoniae Could endure contact with raised concentrations of chlohexidine, which these ailments could lead to resistance to antibiotics that are commonly used. They selected special breeds of K. pneumoniae which were also representative of isolates routinely seen at the practice. Chlorhexidine is a Frequent ingredient … Read more

DM is God’s gift to managed care. Or is it? Here is a discussion of areas that make evaluating a DM program a complex, if not ineffable, proposition. Measuring DM’s Net Effect Is Harder Than You Might Think By Alison Johnson, RN, MBA Also available in PDF Disease management, embraced by both Wall Street and … Read more

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

From the multibillion-dollar struggle over insurance plan to pandemic-related small business reductions, a Florida gynecologist triumphed where significantly more than twelve professional base ball teams along with a iconic Hollywood restaurant failed. As Covid-19 sparked government-ordered shut-downs at March, judges have disregarded a lot more than four times because much business-interruption suits since they will … Read more

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

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

It is not often in the Middle of an antitrust Struggle that the General Public Take a peek at the gamesmanship that is happening behind the scenes. At how health insurance Aetna is currently making its instance to acquire competitor Humana — and also brand new insight in to Aetna’s decision announced Tuesday to grab … Read more

The whole is often greater than the sum of its parts, and that is proving to be the case with health plans. Will we end up with just 4 or 5 competitors? Contributing Editor Strategically speaking, the executives at John Deere Health Care could see themselves being outflanked by the competition. For years, the managed … Read more

Passing a physician negotiation bill is one thing. Implementing it is another. After months of public comment, Texas Attorney General John Cornyn and the Texas Medical Association finally seem satisfied that rules that took effect June 6 can make the state’s unique physician negotiation law work the way that it’s supposed to. Under federal antitrust … Read more

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

Though HMOs that used PBM-developed formularies increased from 10% of all HMO formularies in 2008 to 11.3% in 2009, 76.6% still develop their formularies internally. Health plans often outsource their formulary administration as a means for better benefit management.   Source: Sanofi Aventis, “Managed Care Digest Series, HMO-PPO Digest,” 2010-2011

It has been a long time since Doug Ross, Mark Greene, Carol Hathaway, and the demanding Peter Benton were saving lives every week on our television screens (Carter, too, although he was often fumbling at the beginning). For some of us, though, it’s difficult not to think about the images and associations from the ER television series … Read more

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

There are many reasons to develop health plan report cards. Just don’t expect most beneficiaries to make use of them. Over the past few years, considerable effort has been devoted to developing health plan report cards. Policy makers believe that if consumers are given detailed information about the quality of health care plans available to … Read more

MANAGED CARE OUTLOOK NPs & PAs — top hiring priority for medical groups Teamwork will be the goal of care delivery systems in the near future, according to a survey of physician groups conducted by Cejka Search and the American Group Medical Association. The success of accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) … Read more

Online or app-based “chatbots” evaluate symptoms 24/7 and could make health care more accessible and effective. But are they just another toy for the tech‑privileged? Dx populi Apps and smarthphones have made symptom checkers available to the public. P​atients who are worried about symptoms in the middle of the night don’t have to run out to … Read more

Johnson & Johnson said its medication, Tremfya, has been found to be effective when compared to the usual rival medicine from Novartis AG at lessening the seriousness and influenced area in adults using moderate-to-severe plaque psoriasis at a latestage study. After 48 weeks of therapy, 84.5 per cent of those 1,048 participants medicated with Tremfya … Read more

Although there aren’t any perfect solutions to creating a formulary free of drug-drug interactions, there are things you can do to limit problems. Sometimes even the best-laid treatment plans can crash upon a pharmacy counter, where dangerous — even deadly — combinations of prescription drugs are too often dispensed. Pharmacists don’t want to make errors, … Read more

The e-prescribing movement is getting some new advocates –employers. Can the combined influence of plans, employers, and the government affect physician buy-in? Nothing is more appealing than an idea that promises to improve both patient safety and the bottom line. That’s the potential of electronic prescribing. But implementation is complicated and expensive. Without the financial … Read more

This series of deleterious events interrupts the pathophysiological process resulting in an acute coronary disease. Landmark trials also have established aspirin, and also the inclusion of clopidogrel to aspirin, also because key curative agents at the context of severe coronary syndrome along with percutaneous coronary intervention. Double antiplatelet therapy has become the guideline-mandated quality of … Read more

The push to integrate health care services and financing may portend a move away from behavioral health carve-outs Managed care sure bent the cost curve, all right — at least, in the area of behavioral health care. From 1986 to 2005, the last year for which comparable data are available, the share of health care … Read more

The total number of hospital beds in the U.S. has been declining for decades. “Care is increasingly shifting from inpatient settings to outpatient settings,” says Marie Johnson of the American Hospital Association. The list of reasons is long, its ordering in the eye of the beholder: Cost pressures, mergers, surgical innovations that mean shorter stays, … Read more

Abstract Purpose: Using New York City as an example, this research explores reasons for the consistently poor financial performance of three start-up health plans (Health Republic, CareConnect, and Oscar) while other health plans have performed relatively well in the same market. Design and Methods: This study compiles insurer data from financial years 2014 through 2016, submitted to … Read more

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

Google’s engineers are working with the United Nations Children’s Emergency Fund (UNICEF) to analyze data in an effort to map and anticipate the spread of the Zika virus, according to a Reuters report. Google said in a statement that it was providing a $1 million grant to UNICEF to help the agency’s volunteers on the … Read more

This competitor of clopidogrel will probably be most useful for patients in the initial phases of acute coronary syndrome Looking at just the primary diagnosis on hospital discharge data, acute coronary syndrome (ACS), which includes patients with acute myocardial infarction or unstable angina, accounted for nearly three quarters of a million hospital discharges in 2006, … Read more

Mildred Beam-Rucker, JD Managed care is a business. Each party to a potential managed care agreement has a number of business and economic considerations. Both parties want a profitable relationship, and while profitability is important, providers and managed care organizations seem to have more success when they identify a joint mission for the relationship and … Read more

Although a recent article in the Wall Street Journal described many companies’ efforts to link employees’ performance to their salaries as “lackluster,” Hill Physicians Medical Group in San Ramon, Calif., has reason to crow. The group, with more than 2,100 physicians, paid those physicians $12 million in bonuses. Included in the distribution was $5.6 million … Read more

Many facts are widely circulated about generic drugs, including these: Today, 7 out of 10 prescriptions are filled with generic drugs. The average price of a generic drug prescription is just under one fourth the average price of a brand drug prescription: $35.22 vs. $137.90. Almost 80 percent of FDA-approved drugs have generic counterparts — … Read more

COVER STORY Is Bundled Payment an Idea Whose Time Has Come? For decades, managed care plans have sought to stop paying fees for services. Now they’re trying bundled payments for episodes of care. Joseph Burns Cloud Computing Puts Stakeholders On Same Page It might not be the road to totally overcoming the fractured nature of … Read more

Because specialty drug expenditures will grow, P&T committees may become more involved with drugs provided under the medical benefit   Specialty pharmaceuticals have contributed substantially to the rise in the nation’s drug bill over the last several years. Given their presence in the FDA pipeline, they are expected to continue to do so. Without a … Read more

In case you hadn’t noticed, employers and insurers are engaged in a headlong process of transferring health care costs to the insured employees. The term “price sensitivity” also is used a lot, the idea being that you might not push for that medically-optional, expensive drug, procedure or test. But while there’s logic and evidence that … Read more

Managed care-driven changes in care delivery and reimbursement have caused a lot of hospitals to close beds and convert nursing units to outpatient centers. But some health care planners are warning hospitaladministrators not to become myopic: Giving up beds and renovating units now could come back to bite in about 10 years, when baby boomers … Read more

Using lower cost generic prescription drugs is vital to holding down the growth rate of health care spending. A new report from the Generic Pharmaceutical Association identifies generic agents in the cardiovascular and central nervous system (CNS) categories as delivering nearly 60 percent of the saving. Generic CNS medications have contributed significantly to the increase … Read more

2017 is appearing to be a major carry out year for biosimilars in the U.S. Late in November, Pfizer dispatched Inflectra at a 15 percent rebate. Be that as it may, investigators from Sanford Bernstein expect Inflectra take-up will be delayed for the primary portion of 2017, just speeding up in the later piece of … Read more

Cigna has jumped into the ongoing EpiPen controversy with both feet with its decision to not cover the brand version of the product without first giving prior authorization, STAT reports. With about 15 million beneficiaries, Cigna is the first major health insurance company to take this stand. Cigna also insists on giving prior authorization to an EpiPen competitor, … Read more

Name Last modified Size Description Parent Directory 28-Aug-2000 11:10 – 9808.news_whatstheri..> 29-May-2000 11:52 1k 9808.news_newdrugs.s..> 29-May-2000 11:52 1k 9808.washington_gord..> 29-May-2000 11:54 1k 9808.washington_tele..> 29-May-2000 11:54 1k 9808.news_wheres.shtml 29-May-2000 11:52 1k 9808.news_headlines…> 29-May-2000 11:52 1k 9808.states_kentucky..> 29-May-2000 11:53 1k 9808.washington_some..> 29-May-2000 11:54 1k 9808.compmon.shtml 29-May-2000 11:52 2k 9808.washington_medp..> 29-May-2000 11:54 2k 9808.states_texas.shtml 29-May-2000 11:53 2k 9808.washington_take..> … Read more

Health plan clinical administrators can take much better advantage of the low prices of pharmaceuticals that become untethered to a brand name The coming fiscal cliff continues to dominate Americans’ attention. But sitting in your health plan’s offices and trying to achieve lower health plan costs, it’s the patent cliff — not the fiscal cliff … Read more

Name Last modified Size Description Parent Directory 11-Jan-2005 13:10 – ../../../archives/0001/0001.compmon.gif 01-Jan-2000 12:00 39k ../../../archives/0001/0001.compmon.pdf 01-Jan-2000 12:00 42k ../../../archives/0001/0001.cover.jpg 01-Jan-2000 12:00 10k 0001.dmpac.chartpac…> 01-Jan-2000 12:00 12k 0001.dmpac.chartpac…> 01-Jan-2000 12:00 15k 0001.dmpac.chartpac…> 01-Jan-2000 12:00 15k 0001.dmpac.chartpac…> 01-Jan-2000 12:00 16k 0001.dmpac.chartpac…> 01-Jan-2000 12:00 8k 0001.dmpac.chartpac…> 01-Jan-2000 12:00 7k ../../../archives/0001/0001.dmpac.chartpac.pdf 01-Jan-2000 12:00 108k ../../../archives/0001/0001.news_lackcov.gif 01-Jan-2000 12:00 34k ../../../archives/0001/0001.outlook.gif … Read more

Strategic pricing doesn’t have to be a race to the bottom. Before I explain why, let me share a little context. CMS’s recent requirement to post charges online has increased the need for hospitals and health systems to have a comprehensive pricing strategy. Many health systems I work with often think being more transparent—either through … Read more

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

Providers are not the only ones who need to encourage employees to get more involved with their care, a study argues Health insurers can play a crucial role in fostering patient engagement, according to a study that looks at how UnitedHealthcare encouraged some of its beneficiaries, including about 133,000 of its employees, to become more … Read more

January 2003 February 2003 March 2003 April 2003 May 2003 June 2003 July 2003 August 2003 September 2003 October 2003 November 2003 December 2003

Medco predicts in its 2010 Drug Trend Report that over the next three years, medications in 6 of 16 broad categories will account for about 72 percent of drug cost and utilization. Leading the way will be agents in the central nervous system and endocrine and diabetes categories, which when combined will account for 40 … Read more

VBID is a promising approach to improving health and cost outcomes, but its use has been limited. Expanding it to complicated interventions will require a lot of effort. The history of managed care is littered with the debris of failed ideas. Capitation, anyone? It led directly to the managed care backlash. Remember provider-owned HMOs? They … Read more

Submitted by Steven Peskin MD on Mon, 2012-03-12 23:56 So many gaps, so little time…. That would be a ready conclusion from the extensive body of literature on gaps in patient care, medical errors, and patient safety. A recently released in-depth report from the American Medical Association,  Research in Ambulatory Patient Safety, chronicles gaps related to … Read more

Time For An Overhaul: CMS Wants to Remodel Cancer Payment, Care CMS’ Oncology Care Model program is bringing bundled payments to cancer care. With drug costs so high and hard to control, the 195 participating practices will have to figure out other ways to control costs if they want to beat financial benchmarks and earn … Read more

“The results found in such critical Phase 3 studies reveal that crisaborole, when approved, can possibly be quite a purposeful treatment option for patients who have mild to moderate atopic dermatitis” The comprehensive results from the Pivotal Phase 3 studies demonstrated that crisaborole achieved mathematically significant effects on secondary and primary end points for its … Read more

Aetna’s chief medical director for Medicare draws on years of experience to chart opportunities and challenges of the new legislation’s focus on innovation Aetna’s chief medical director for Medicare draws on years of experience to chart opportunities and challenges of the new legislation’s focus on innovation You can always learn something from a pilot program … Read more

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

CEO testifies to Pilgrim’s progress: Web helps HMO sail into black ink Harvard Pilgrim lost $20 million in the first eight months of the year, but the HMO is starting to break even and expects to be making money on a monthly basis by the end of the year, its chief said yesterday. [Boston Herald … Read more

In what is being hailed — or scorned, depending upon the source — as a major victory for the health care industry, the Bush administration has issued proposed revisions to privacy regulations. As the New York Times reports, the revisions, issued March 21, do away with a rule that says health plans, physicians, and hospitals … Read more

Issues like HMO solvency, physician antitrust waivers, and external review come and go, but you’ll find scope-of-practice bills in state legislatures year after year. State laws determine what optometrists, naturopaths, psychologists, and other allied health practitioners can do. Despite vigorous opposition from state medical associations, scope-of-practice bills succeed in changing those laws every year. “You … Read more

Some powerful business groups charge that association health plans, one of the cornerstones of the Bush administration’s attempt to reform the medical system, would harm those companies that choose not to participate. Also, say opponents, AHPs would lead to expensive federal regulations, unpaid medical bills, and increased marketplace fraud. The U.S. Chamber of Commerce, and … Read more

BY NEIL CAESAR, J.D. Last month, we lamented some physicians’ indifference towards the contract negotiation process–the result of which is unprofitable, impractical managed care contracts. This attitude makes it unlikely that a managed care organization will view any such physician as a premier partner deserving of special entitlements or responsibilities. Instead, managed care will become … Read more

More difficult than ever to pull off, health care on a fixed, per-capita budget has gone out of style in a number of areas. But many things are cyclical – and this trend may be, too. Michael D. Dalzell Managing Editor If there ever was an aspect of managed care so simple in theory, yet … Read more

Can ICER bring cost-effectiveness to drug prices? Insurers and pharmaceutical companies want ICER to umpire debates about drug prices. But some question the cost-effectiveness calculations of the Boston not-for-profit and its dependence on QALYs. Even Small Employers Are Striking Out on Their Own Risk doesn’t faze companies as much as rising premiums, and stop-loss offers some … Read more

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

Ost hospitals don’t fit with the Leap Frog Group’s minimum volume requirements for eight speculative procedures, as found by your report published Thursday by the organization.To choose the eight approaches, leap-frog examined countless studies Conducted at the previous ten decades and looked over guidance from Leap Frog’s National Inpatient Surgery Expert Panel. No medication without … Read more

The American Academy of Family Physicians wants to provide members with some form of electronic medical records. This is downright visionary. Too bad it can’t work. One reason: More information means more work for doctors, not less. “That’ll be the day.” — Buddy Holly I recently responded to a survey from the American Academy of … Read more

Fifty is a nifty number when considering how to cut back the care given in emergency rooms for nonemergency problems, according to a recent study. It seems that levying a copayment of $50 or more results in a significant reduction in ER use for non-emergent conditions. “Copayment Levels and Their Influence on Patient Behavior in … Read more

Most doctors who are in the process of moving out of clinical practice and into the role of a physician executive either have obtained, or are in the process of obtaining, a post-graduate business degree, says Lois Dister, the senior vice president at Cejka & Co. She should know. Cejka conducts a physician executive compensation … Read more

Hal Hoffman’s work led to the discovery of the genetic basis of an autosomal dominant disease and to creation of a prototypical orphan drug Thomas Morrow, MD We seldom describe a single contemporary practicing physician in the United States as a pioneer, but that term would truly describe Hal Hoffman, MD, a pediatric allergist in … Read more

The perception that DM is merely a drug marketing tool seems finally to have vanished from this healthy, though fragmented, industry. In 1993, Eli Lilly announced it was turning itself from a drug company into a disease management company. It wasn’t long before other pharmaceutical giants, including Merck, Glaxo, Pfizer, and SmithKline Beecham, made similar … Read more

If the ACA reaches the Congressional Budget Office (CBO) prediction of 21 million Americans covered by marketplace health insurance in 2016, it will be the law’s single most important achievement since its recovery from a disastrous rollout. But it’s not going to happen. In March of this year, the CBO said that when the federal … Read more

Also available in PDF Using database analysis, this study documents various resources consumed as part of routine management of suspected meningitis, culminating with a discharge with a diagnosis of viral meningitis. Abstract Purpose: This study involved identifying resource use and assigning monetary value to the diagnostic work-up and management of viral meningitis. Methodology: Using a … Read more

Have hospitals adopted managed care’s regimen of efficiency as standard operating practice? A new Milliman & Robertson survey suggests that when it comes to hospitalization, medical/surgical lengths of stay are not heavily influenced by what it says on a patient’s insurance card. In 11 states where M&R studied discharge data, lengths of stay for commercial … Read more

So deadly it’s considered a terrorist threat, carfentanil has been legal in China—until now. Beijing is banning carfentanil and three similar drugs as of March 1, China’s Ministry of Public Security said Thursday, closing a major regulatory loophole in the fight to end America’s opioid epidemic. “It shows China’s attitude as a responsible big country,” … Read more

In a study of nearly 650 people with age-related macular degeneration (AMD), half still had vision 20/40 or better, typically good enough to drive or to read standard print, after five years of treatment with anti-VEGF drugs that are injected into the eye. The authors of the study, funded by the National Eye Institute (NEI), … Read more

Self-referral is not the biggest contributor to the growth of in-office imaging by physicians, according to a report prepared by the Lewin Group for a coalition of physicians and medical groups. Rather, it’s the immediate access to imaging results and the expanded uses for diagnostic imaging that drive the growth of these technologies. The report … Read more

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 is overdue for blood monitoring for diabetes and cholesterol, and that she should have a mammogram. But the flags … Read more

ACOs Produce Good Cost and Quality Results Maybe, just maybe, accountable care organizations (ACOs) are the best bet for hitting the health care exacta of controlling costs and improving the quality of care. Figures released by CMS on September 16 showed that the 23 organizations in the elite Pioneer program and 220 in the Shared Savings program … Read more

In the Nov. 26, 1927, issue of the Journal of the American Medical Association, M. L. Harris, M.D., wrote a special article called “Medical Economics.” It reads, in part: Contract practice per se is not unethical…. It may be said, however, that a contract is unfair and therefore unethical when the compensation received is inadequate … Read more

January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014 December 2014 Trending Medicare biosimilar reimbursement: Hopes for cost savings, a dream deferred Cost of Cancer Drugs: Something Has To Give Violence Against Nurses: Casualties of Caring Home Hospital Halves Costs Altarum’s MESA Turns High-Deductible Coverage on its Head

Congress wanted to know if it would be OK for pharmacy benefits managers to participate in Medicare Part D. Answer: Yes. John Carroll Early on in discussions about the new Medicare drug subsidy, drugstores zeroed in on a sore point: allowing the big pharmaceutical benefit managers’ mail-order operations to handle drug orders for beneficiaries. There’s … Read more

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

Ixekizumab Helps Psoriasis Patients Who Did Not Respond to Etanercept Monoclonal antibody shows promise in phase 3 trial   Patients with moderate-to-severe plaque psoriasis who did not respond to treatment with etanercept (Enbrel, Amgen) achieved significant improvement in their psoriasis plaques when treated with ixekizumab (Eli Lilly) in a phase 3 study. Results from the … Read more

Duodenoscopes are utilized in a lot greater than 500,000 techniques per year since a far much less invasive manner than conventional operation to drain fluids in pancreatic and pancreatic ducts obstructed with lymph nodes, endometriosis or some other autoimmune problems. The elastic lighted duodenoscope, that will be threaded through the mouth in to the very … Read more

Cigna, That Could have Already Been acquired by Anthem, says it Is the Injured party and continues to be demanding roughly $15 billion. Anthem, that conducts Blue Cross and Blue Shield plans in greater than twelve countries, insists it has owed $20 billion because Cigna pulled its feet to undermine the bargain. The situation provides … Read more

Results from LUX-Lung 7, also a international headtohead Stage IIb trial comparing treatment by Gilotrif® into Iressa® in patients whose tumors shield the most frequently encountered EGFR mutationsthat have been released in The Lancet Oncology. Manager of Complex Cancer Medicine Institute in Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea remarked,”This important … 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

To analyze the epidemiology of childhood soccer-related injuries treated in emergency departments within the USA. Injury rates were calculated out of football involvement data. Even the yearly accident rate per 10 000 football participants climbed somewhat, by 111.4 percent, by 1990 to 2014. Patients 12 to 17 years of age accounted for 72.7percent of harms, … Read more

Drug pricing & markets, value-based pricing, cost control, real-world evidence for safety and effectiveness DRUG MANAGEMENT Generics of the Authorized Kind FRIEDA WILEY They can add competition and lower prices, but some see authorized generics as a ploy to fend off competition from true generics. DRUG MANAGEMENT Prime Sees Dip in Opioids, Triptans as CGRP Inhibitor … Read more

As costs for treating back pain skyrocket, some stakeholders turn to a team approach featuring this little-used specialist. Football or futbol? The senior leaders in American health care grew up in an era of punt, pass, and kick. American society is transitioning toward the international game with a round ball, which requires blurring of roles … Read more

Is there a concept in health care that has taken root and blossomed so fast as disease management? One that has captured the imagination and attention of the employers who pay for most of the nation’s health care? Data collected last year by the National Managed Health Care Congress and Migliara/Kaplan Associates indicate that employers … Read more

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

Health insurers are experiencing a shift in the sources of revenue, with factors like the downturn in the economy and the changing demographics of members playing a major role, according to a report from Mark Farrah Associates, an aggregator and publisher of health plan market data. The report says U.S. health plan revenues totaled $370.8 … Read more

A study by the Rand Corp. suggests that high managed care penetration in urban areas is forcing a slow but tangible physician migration to the country — away from HMOs. Rand followed 75,000 doctors who finished graduate medical education between 1989 and 1994. Early in the period, primary care physicians tended to settle in metropolitan … Read more

It seems that everyone is jumping on this bandwagon, with physician specialists even participating. Will the big PBMs come to dominate this market too? Martin Sipkoff As the population ages, specialty pharmacy is becoming a unique, profitable, and invaluable delivery system. Plans are increasingly turning to specialty pharmacies to provide the expertise they lack. “Specialty … Read more

Managed care, it seems, is least rewarding for those physicians who are most immersed in it: the medical directors. A report from Ernst & Young, the giant worldwide accounting and consulting firm, implies that medical director income varies inversely with administrative duties. While people in this position need to have all the skills of a … Read more

Aetna releases a five-year study showing that companies that do this correctly can enjoy impressive savings Consumer-directed health care, in which so many have placed so much hope for so little return, at least in terms of the number of enrollees, comes with a structural defect. Companies have decided that if they offer a consumer-directed … Read more

Harry S. Truman once said that the “only thing new in the world is the history you don’t know,” to which someone might flippantly rejoin that our plainspoken midcentury president had never had to program a VCR. However, Truman, if you recall, did wrestle with new technology — with the monster hatched by the Manhattan … Read more

A potential useful volume on ethics in critical care falls short of expectations, often skimming the surface of important debates Michael S. Victoroff, MD I have been invited to review a publication from the Society of Critical Care Medicine titled Critical Care Ethics: A Practice Guide from the ACCM Ethics Committee, edited by Dan R. Thompson, … Read more

Deliver hospital-level care in people’s homes to achieve better outcomes and save money. Internist and researcher David Levine, MD, has nothing against hospitals. After all, he works for one—Boston’s Brigham and Women’s. “Hospitals are an important part of American health care, and we need them for the very complex cases,” he says. “But they’re not … Read more

This year’s two presidential nominees have taken aim at high drug prices — and pharma. A solution may require not just rhetoric but cooperation between industries. This hasn’t been the best of years for the pharmaceutical industry on Capitol Hill. Even with pro-business Republicans running the show in Congress, pharma executives could not avoid being … Read more

New therapies that manipulate the immune system offer hope to patients and pose challenges to managed care. New therapies that manipulate the immune system offer hope to patients and pose challenges to managed care. Psoriasis treatment is undergoing a revolutionary change. In the past, serendipity played a major role in the development of new therapies. … Read more

Linkedin Share Button(link is external) Tweet Widget(link is external) Share on Facebook(link is external) There’s a lot of support and momentum behind telemedicine, as the cover story in Managed Care’s July issue well documented. Videoconferencing, text messaging, and email mean that the treatment option might soon become common practice. Maybe. There are still significant roadblocks, as … Read more

As large companies become more demanding of health plans, clinical executives are increasingly being relied on to provide advice and expertise. Four years ago, Capital Health Plan in Tallahassee, Fla., embarked on a wellness program with a large employer in the area. The health plan designed presentations on chronic conditions, for example, but few people … Read more

Michael S. Victoroff, M.D. At one time, I thought I understood how medicine could be an art. However, after hearing “art” invoked too often as an excuse for error, I wonder if we should reconsider the whole proposition. The Russian poet Yevgeny Yevtushenko wrote some verse in the 1960s critical of the state of art … Read more

In January, a new venture investment fund opened in Boston with $42 million in its pocket and a goal of raising $80 million within two years. The new fund, called the JDRF T1D Fund, quickly invested in three early-stage start-ups. Just like traditional venture capital funds, the T1D Fund plans to work closely with start-ups … Read more

For the second straight year, California Gov. Pete Wilson cited the prospect of rising health costs as he vetoed a host of managed care reform bills passed by the state legislature.In the weeks after the end of the legislative session, Wilson vetoed seven managed care reform bills, including three that would have tightened regulation of … Read more

Should Real Estate Be Part of a Practice Buy-In? When physicians invite a new partner into a practice, it raises the question of whether he or she should be required to invest in the practice’s real estate holdings. Here’s what to consider in making that decision. Daniel M. Bernick, J.D., M.B.A. Help Your Patients EAT … Read more

State Laws on Biosimilars May Drive Up Plans’ Costs As different sectors of the drug industry battle, pharmacists may follow the easier — and more expensive — path John Carroll Back in mid-May, the governor of Virginia signed off on a law that sets up some ground rules on when and how pharmacists will be … Read more

State lawmakers want hospitals to reveal what they’ve negotiated with health plans for lists of services that grow ever longer John Carroll A few weeks ago the North Carolina legislature significantly upped the ante on what qualifies as price transparency in the health care industry. Lawmakers easily passed a bill that requires hospitals in the … Read more

The House has passed legislation that the AMA and others endorse. But the sense that there is a malpractice crisis has ebbed and Senate action is unlikely. You may remember Y2K: anxiety that computers would crash, trains would stop running, and the electric grid would shut down. Turns out it was hype, and at 12:00:01 … Read more

“If I were queen of managed care…,” muses the president of the New England Healthcare Institute, who wants to see how new technologies fit in with the entire system, not just pieces of it. As president of the New England Healthcare Institute (NEHI), Wendy Everett, ScD, heads an organization whose board includes insurers, purchasers, suppliers, … Read more

Say what you will about capitation (and a lot has been said), it did help to put the brakes on costs in the 1990s. Now, according to the Segal Co., the West may well experience higher claims thanks to “the erosion of prepaid … arrangements … (which was the predominant method of reimbursement for many … Read more

Reform may not address the real question   As a macroeconomist and someone who has been helping the Centers for Medicare and Medicaid Services take the long view of health care costs for years, Thomas E. Getzen, PhD, sees only a partial fix in the works in Washington. Something big will happen, he predicts, but … Read more

They too often focus narrowly on the work of oncologists, when a much more comprehensive approach is needed Cancer is a major service line for most hospitals. It is one of the largest revenue producers and it is seen as a growth opportunity as the number of cancer diagnoses continues to increase in an aging … Read more

Good news for people who work in the health insurance industry: Median salary budgets (the total available budget to invest in employees through salary) for 2011 are expected to rise 2.9 percent for executives and 3 percent for all other employee levels, the Hay Group reports. Last year, the median salary budget increased 2 percent … Read more

It happened in the slump of the early 1990s, and it could very well happen again. Managed care feasts while other industries starve. People will still get sick, even in bad times. By Frank Diamond Senior Editor Whenever Alan Greenspan makes a pronouncement, lawmakers, pundits, and reporters parse the tortured syntax of the Fed chairman’s … Read more

Also available as PDF Total compensation for senior medical managers in HMOs increased, on average, 5 percent last year — similar to growth rates of previous years. According to a study by the Tampa, Fla.-based Physician Executive Management Center, a physician executive search firm, compensation for these people (medical directors, vice presidents for medical affairs, and … Read more