Managed Care
Contributing Voices
Saeed Aminzadeh

As the country’s population of non-native English speakers continues to grow, language differences have become a significant barrier to engaging health plan members and keeping them as healthy as possible.

Last fall, the Census Bureau released data showing that one out of every five U.S. residents doesn't speak English at home.

In fact, the number of people who speak a language other than English at home has reached an all-time high of 61.8 million, up 2.2 million since 2010. The largest increases from 2010 to 2013 were speakers of Spanish, Chinese, and Arabic.

Health plans most  work closely with their members who are non-English speakers.  Population health analytics tell us that language barriers affect care and membership loyalty:

News & Commentary
Lack of insurance and poverty heavily influence whether adults take their medications as prescribed, according to a study by the National Center for Health Statistics. About 14% of uninsured adults under 64 skipped medications to save money, compared to 6% of adults who have insurance.
Contributing Voices
Ted Slafsky

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 and rural facilities across the country that care for all patients, regardless of their ability to pay.

Contributing Voices
Frank Diamond

Maybe it’s because cars are fun and we’re young when we start driving that we slide easily into the habit of paying automobile insurance. Or maybe it’s because cars are dangerous and our parents and/or the state wouldn’t let us drive without it. The metaphor of allowing beneficiaries to buy health insurance as they do car insurance (just this side of hoary when we used it back in 1998: left reality in the dust ages ago. It sounds so nice, but it’s still not happening, according to a Kaiser Family Tracking Poll released in April 2015 (

This, despite all the talk of transparency and the overabundance of evidence that two providers can charge very different prices for the same procedure in the same town and get the same outcomes. This, despite the continuing shift in costs to beneficiaries. In the poll, 2 out of 3 people say that finding out how much doctors or hospitals charge is too difficult. Only 6% of people use quality rankings to make a decision about an insurer, doctor, or hospital.

News & Commentary
Now the IOM is calling it systemic exertion intolerance disease (SEID), and hopes that the new designation will dispel the belief among some providers that the condition is psychogenic. SEID’s economic costs range from $17 billion to $24 billion annually, the IOM says.
About 1 in 3 women in the United States will have a hysterectomy by the time they’re 60. Unfortunately, many do not fully explore alternative treatments such as hormonal therapy, pain management, levonorgestrel IUD, hysteroscopy, and endometrial ablation. Women younger than 40 are more likely to consider such treatments.
Susan Worley

Ella Kazerooni, MD

Screening rates for the deadliest of cancers have languished, but recent rulings by CMS and the U.S. Preventive Services Task Force mean nearly universal coverage for low-dose CT scans. The cost-effectiveness of this effort for payers will depend on skillful implementation.
Contributing Voices
Frank Diamond
Mehmet Oz - World Economic Forum Annual Meeting 2012

In the land of Oz, you can take a pill that makes you lose weight. In the land of Oz, endive, red onion, and sea bass decrease the likelihood of ovarian cancer by 75%. In the land of Oz, acupuncture can help patients stop smoking, lose weight, and even avoid colds.

Mehmet Oz, MD, a national talk show host started his career as one of the best heart transplant surgeons in the world, practicing at Columbia and New York-Presbyterian Hospital.

Now, he’s under fire for allegedly peddling quackery. Ten physicians wrote to Columbia on Wednesday demanding that the school cut ties with the celebrity doctor who, they wrote, “has manifested an egregious lack of integrity by promoting quack treatments and cures in the interest of personal financial gain.”  

Contributing Voices
Frank Diamond

There are few issues that unite the political polarities these day, but there seems to be consensus emerging about this: We dump too many people in prison, including dumping them on a former coal ash landfill, a situation sparking controversy in a corner of Pennsylvania.

Liberals might see overpopulated prisons as resulting from, say, police profiling, while conservatives might believe, for instance, that there are just too many nonsensical laws on the books. The bottom line: The United States imprisons more people than any other country.

State Correctional Institution (SCI) Fayette County in Pennsylvania, housing 2,000 prisoners and opening in 2003, rests on top of a former coalmine and next to a 500-acre coal ash dump in rural Luzerne township. Not good and possibly unconstitutional, charge two human rights organizations, the Abolitionist Law Center (ALC) and the Human Rights Coalition (HRC) in a recently issued study (

They cite the Eighth Amendment, which forbids cruel and unusual punishment, and building a prison on a “massive toxic coal waste dump” might be just that. Over 40 million tons of coal waste had been dumped on the site “at depths approaching 150 feet in some places.” The study states that, “Ash is regularly seen blowing off the site … and collecting on the houses of local residents as well as the prison grounds at SCI Fayette.”

News & Commentary
Better management of respiratory distress syndrome and broncho-pulmonary dysplasia is the main reason these tiny patients have a much better chance of survival than they did 15 years ago, according to researchers, who examined 6,075 deaths among 22,248 infants from 2000 to 2011.
News & Commentary
There’s uncertainty about how to manage these patients and not miss a life-threatening problem. Patients often can’t describe dizziness, say researchers, and those with syncope may not recall if they actually lost consciousness. There needs to be a clinical algorithm to determine just who should get a CT scan.
Legislation & Regulation
Richard Mark Kirkner

Ellyn Sternfield

What started out as a charitable campaign has morphed into a hospital and pharmacy enrichment scheme. There’s a lack of regulation and oversight. Think of it as a shell game. The more hands that move the drugs around, the more difficult accountability becomes.
Managed Care Outlook
The Catalyst for Payment Reform (CPR) reported that in 2013 just 11% of payment to providers was not under an FFS model. CPR’s second report card last year found that 40% of commercial health plan payments were made through payment methods designed to improve quality and reduce waste.
Contributing Voices
Peter Wehrwein

Sovaldi, Harvoni, Viekira Pak, a slew of oncology meds—they’re all contributing to specialty pharmacy sticker shock.

Ivacaftor (Kalydeco) for cystic fibrosis hasn’t been in the news quite as much, but priced at $300,000 per year, it’s also part of the trend of super-high-priced drugs that is sweeping American health care.

Approved by the FDA two years ago, ivacaftor targets a particular genetic mutation that affects only about 4% of people with cystic fibrosis, so despite that stratospheric price, it hasn’t had the same effect on budgets as the hepatitis C drugs like Sovaldi or, increasingly, expensive cancer drugs.

One of our regular contributors, Krishna Patel, wrote about ivacaftor in this month’s issue of Managed Care, and her takeaway was for payers to follow the guidelines for ivacaftor and not erect obstacles to people getting a drug that might make a huge difference in their lives.

But the FDA is expected to approve a new medication some time this year that combines ivacaftor with another medication, lumacaftor. And rather than working in small percentage of people with cystic fibrosis, this new combination is expected to be effective in roughly half of those with the cystic fibrosis who are ages 12 and older.

Kevin Bowen and Patrick Gleason of Prime Therapeutics are presenting a poster today at the annual meeting of Academy of Managed Care Pharmacy in San Diego that gives some estimates of the financial consequences of this new drug on health plans and other payers.

Managed Care Outlook
An announced overhaul of Medicare would mean that 30% of payments for fee-for-service beneficiaries would be funneled through alternative payment models by next year and 50% by 2018. The shift would rely on accountable care organizations, bundled payments, and medical homes. Can CMS pull this off?