Jason Duhon
CMS depends on encounter data submitted by state Medicaid programs to maintain the massive Medicaid Statistical Information System (MSIS), a database of claims, encounter data, and beneficiary eligibility information. Poor encounter data can hinder quality measurement in multiple ways.
Ted Slafsky, MPP & Robert Chapman, MD

In an era of rapidly escalating prices, the 340B drug discount program remains one of the few checks to keep medicine and medical care accessible to the underserved. Contrary to the recent column, "Payers Must Develop Strategies To Overcome 340B Hurdles," it is not being exploited by participating hospitals.

If it were, where exactly is the money?

Zachary Hafner
Advisory Board

Zachary Hafner
If you’re still bickering over rate hikes and contract minutiae, then you’re out of step with the new health care economy. In progressive markets, savvy payers and providers that work together rather than constantly bumping heads are pulling ahead at the expense of slow movers and status quo players.
Chuck Hayes

Nearly half (45%) of American adults have a chronic health condition and a quarter have more than one chronic illness. Patients readily admit they do a better job of taking care of themselves when they receive reminders and motivational messages from their health care providers.

Zachary Hafner
Advisory Board

Zachary Hafner
The transformation of health care is fundamentally altering the environment in which health systems function, placing the CMO squarely at the center of a new reality where concepts like value, population health management, and outcomes-based payment are becoming key drivers of success.

Michael Schlosser, MD

Michael Schlosser, MD
Physicians, more than anyone else, can influence peers when it comes to talking about evidence-based care, even when it runs counter to customary, but costly, practice patterns. The timing couldn’t be better to put physicians in this leadership role because of the growing use of value-based payment models.
Zachary Hafner
According to an analysis of Medicare data, 40% of cancer patients have one or more comorbidities and 15% have two or more, the most common of which are diabetes, chronic obstructive pulmonary disease, and congestive heart failure. These diseases can complicate cancer care on many levels.
Richard G. Stefanacci, DO
Donald Ohioma, MS
Perhaps ACOs may be the answer to striking the right balance between utilization and clinical outcomes. But there’s a problem. They are not responsible for the costs of drugs covered by Medicare Part D plans in their total cost of care, but they are responsible for the costs of negative outcomes if medical treatment is inadequate or goes awry.
Paul Terry

 A few days ago, I went to the “Poke-stop” in my small town of Waconia, Minnesota, (population 11,490) to learn why I was losing my Pokémon “gym battles” and, more importantly, to survey the growing numbers of twentysomethings exploring my community’s parks and landmarks. I met a group of 15 Waconians for the first time, and they were excited about describing how Pokémon Go had increased their activity levels, their awareness of our community’s history, and their engagement with others.

Saskia Siderow
Allison Silvers, MBA
Diane E. Meier, MD
Palliative care has become America’s fastest growing medical specialty. ere are now more than 6,500 physicians and 13,500 nurses certified in palliative care, and palliative care teams available in more than 80% of American hospitals with more than 50 beds.
Paul Terry

With the support of the Robert Wood Johnson Foundation, 35 of us visited the Lincoln Cottage, a hilltop retreat overlooking D.C. where Lincoln found solace, but also connected more closely with people, during the Civil War. Our group was there to inaugurate a national dialogue on health equity. Later dubbed the “Lincoln Cottage Assembly,” we were welcomed by health futurist Jonathan Peck at the staircase Lincoln climbed every day to write about the most vexing issue of his time.

Jonathan Gavras, MD

Our country is in crisis. We have an epidemic on our hands that crosses geographic boundaries, socio-economic status, gender, and many other categories. According to the American Society of Addiction Medicine, drug overdoses kill nearly 50,000 Americans each year. The media is certainly putting a microscope on it. Legislators are acting on it. Every stakeholder in the medical delivery chain is analyzing it–and I encourage physicians and other prescribers to take a look at their role in the problem.

Richard G. Stefanacci, DO
Scott Guerin, PhD

American health care has been moving away from dependence on PCPs for decades. The continued erosion of primary care practice by non-PCPs such as patient navigators, and nurse practitioners will surely mean that the corner PCP office serving FFS Medicare patients is quickly going, going, gone....

Rita E. Numerof
Michael N. Abrams
Private health insurers are in a perilous position these days. But along with peril comes the opportunity to make disruptive changes and seize substantial market share. Leaders throughout the health care insurance industry must be proactive about initiating business model innovation.
Aiden Spencer

Paper or plastic? Debit or credit? Netflix or Amazon? These are the kind of choices we are asked to make everyday. They are not, though, the type of decisions that keep us up at night.

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Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.