Managed Care


ACO Update
Peter Wehrwein
The lesson of why some plans opted out of the CMS program is another reminder that in health care, especially in managed health care, it so often comes down to the details. Tweak the financial benchmarks so that regional differences are taken into account, and there may be fewer dropouts.
Contributing Voices
John Marcille

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

Medication Management
Thomas Reinke
The FDA and industry experts predict that the quality of pharmacogenomic information will improve and that the role of such testing will expand as the cost of genetic testing plummets and as evidence mounts for relationships between drugs and specific genetic variants.
John Marcille
Mark. W. Friedberg, MD, one of the foremost experts on the patient-centered medical home explains why the high-profile failures of some recent demonstration projects shouldn’t mean the end for this care delivery system. The challenges can be overcome with some different approaches.
Contributing Voices
Norman S. Ryan, MD

As if the worsening diabetes epidemic were not enough to worry about, this chronic condition also increases risk for complications like heart disease, stroke, and kidney failure. This is a major challenge for health plans managing the care of a growing population of Medicaid members, who tend to overutilize emergency rooms for routine or non-urgent care.

While preventive and disease management programs are helping improve outcomes for people with diabetes and other chronic conditions, more must be done beyond just phone outreach to adequately engage Medicaid members. For instance, the single mother with young children and no car doesn’t need a call to remind her of an A1C test; she needs help resolving socioeconomic barriers like lack of transportation or child care.

Legislation & Regulation
Richard Mark Kirkner
The Centers for Medicare & Medicaid Services and Congress want to make it impossible for insurers to change provider networks after the enrollment period. The backdrop for this is that enrollment in Medicare Advantage plans has grown at four times the rate of overall Medicare.
Cover Story
Joseph Burns
One of the means being explored is a laboratory formulary. If the utility of a certain test is questionable, then it might not be available to all ordering physicians. This not only helps to cut lab tests, but very often relieves some of the financial burden on patients.

You’ve seen some of P.C. Vey’s work in the New Yorker and a host of other national publications. We asked him to look for the lighter side of managed care and — dagnabbit! — turns out there’s a wealth of material in the tasks medical directors and physicians perform each day. Enjoy!

“I’m softening my position on the spending binge the doctors have planned for my health care.”

Editor's Memo
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 City to pick up a homeless woman and her disabled son.

That was the beginning of a remarkable comeback, as reported by Contributing Editor Joseph Burns.

News & Commentary
Prescriptions for antibiotics given over the telephone jumped from 2.2 per 100 patient-years in 2006 to 4.4 in 2010, according to a study in the journal Pharmacoepidemiology and Drug Safety. Of the total 63,418 antibiotics prescribed in the network during this period, 7,876 were prescribed over the phone.
News & Commentary
The dangers have been greatly overstated, and the medications may even deliver benefits other than the ability to lower cholesterol. Researchers don’t find a big link to diabetes or even muscle aches. On the other hand, statins may actually decrease the risk of pancreatitis.
News & Commentary
Yes, says a study in the journal Science Translational Medicine. The virus blocks an immune system response that might otherwise lead the body to reject the transplanted organ. Interesting though this finding is, it could be moot thanks to the blockbuster new drugs for the disease.
The Formulary Files
Krishna Rutvij Patel, PharmD
Adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) were among the 10 drugs with highest revenue in the past year, even though Humira and Enbrel were only among the 100 most prescribed drugs and Remicade didn’t even make that list.

“We’re going to see the rapid demise of the onesy-twosy private practice primary care doctor,” says says David B. Nash, MD, MBA, the founding dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia. For one thing, there are not enough of them. 

Watch the full interview with Dr. Nash or read the edited transcript.

Managed Care Outlook
“Because approximately 75% of COPD is caused by smoking, the principal route to primary prevention is the prevention of smoking initiation and smoking cessation among those who smoke,” says a study by the Centers for Disease Control and Prevention. Hospitalizations make up a large portion of the COPD bill.


4th Partnering With ACOs Summit Los Angeles, CA October 27–28, 2014
PCMH & Shared Savings ACO Leadership Summit Nashville, TN November 3–4, 2014
2014 Annual HEDIS® and Star Ratings Symposium Nashville, TN November 3–4, 2014
Medicare Risk Adjustment, Revenue Management, & Star Ratings Fort Lauderdale, FL November 12–14, 2014
World Orphan Drug Congress Europe 2014 Brussels, Belgium November 12–14, 2014
Healthcare Chief Medical Officer Forum Alexandria, VA November 13–14, 2014
Home Care Leadership Summit Atlanta, GA November 17–18, 2014
HealthIMPACT Southeast Tampa, FL January 23, 2015