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Contributing Voices
Steven Peskin, MD

A visit to my dental hygienist this week began with a conversation about diagnostic tests. Before the dental x-rays, I asked Dottie if I needed x-rays, and she replied that it had been 18 months, and, based on my age and past dental history, every year to two years was a reasonable interval. Not wanting to debate this point before confronting the Cavitron, I accepted that rationale.

Contributing Voices
John Marcille

Back in the 1980s, the theme song for the television comedy show Cheers had a line: “Where everybody knows your name and they’re always glad you came.” Now, clinical executives have that place, and its drawing power is not the broad strokes associated with a mammoth social network site like Facebook, but rather, a more focused perspective.

Contributing Voices
Steven Peskin, MD

This post is not about coronary artery disease. Nor is it about the “stiff” ventricles in diastolic heart failure.

Like “Never Rest”, which I posted several weeks ago, this brief discussion was inspired by Saturday morning Torah study. “Harden Heart” refers to the Pharaoh at the time of Moses and the Exodus from Egyptian slavery. What struck me from our discussion on Saturday morning that relates to health plans and health benefits is that those of us who have responsibility/authority over what is reimbursed, or not, how it is reimbursed, and at what level are — metaphorically — in a parallel role to the Higher Power in the Torah passage. Those whom the purchasers and payers are influencing, or who are on the receiving end of attempts at influence by the purchaser or payer are, metaphorically, in the position of Pharaoh (No implication or suggestion intended about virtue or lack thereof on either side of this analogy!). They are employees, plan members, health care professionals and facilities, ancillary providers, and any other entities that are being paid for services.

In the story, it takes many sticks (no carrots) to ultimately influence Pharaoh to free the Jews. The question that we discussed and debated is to what degree God hardened Pharaoh’s heart and to what degree did Pharaoh, using free will, refuse to set the slaves free even in the face of punitive actions — the plagues.

Contributing Voices

The vast majority of Part D plans follow a tiered cost-sharing structure with incentives for members to use less expensive generic and preferred brand-name drugs. Cost-sharing has increased since 2006, but the Kaiser Family Foundation reports in “Analysis of Medicare Prescription Drug Plans in 2011 and Key Trends Since 2006” that there was barely a change between 2010 and 2011.” The foundation reports that since 2006, median cost sharing for a 30-day supply of nonpreferred brand name drugs in stand-alone prescription drug plans (PDPs) increased by 42 percent, from $55 to $78. Preferred brand costs increased 50 percent, from $28 to $42. But since 2010, cost sharing has been stable.

About half of PDP enrollees and over 75 percent of MA-PD plan enrollees are in plans that charge 33 percent coinsurance for specialty drugs. Compared to 2009, this share is down modestly for PDPs but up substantially for MA-PD plans. In contrast, only 4 of the 35 national or near-national PDPs charged a 33 percent coinsurance rate for specialty tier drugs in 2006.

Contributing Voices
John Marcille

It's all about choice these days. Different routes, same destination. In this case, it's reading Managed Care when and where you like, and if you own an iPhone or an iPad, you can do that with our new app available at the Apple Store.

Search for "Managed Care," "P&T," "Biotechnology Healthcare," or "MediMedia," or just click here:
http://itunes.apple.com/us/app/medimedia-managed-markets/id496230488?mt=8

Contributing Voices
Steven Peskin, MD

After grand rounds this morning at the University Medical Center at Princeton, the director of the recently created transitional care program, Kathleen H. Seneca, MSN, was speaking with one of our nephrologists about the purpose of the program. It fills the transitional gap for people discharged from the hospital that do not qualify (in terms of reimbursement guidelines) for home care, but would benefit from additional education, care planning, and hands-on instruction.

Contributing Voices
Steven Peskin, MD

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

Contributing Voices
David Kibbe

Health and Human Services (HHS) just released data on 2010 health expenditures, reporting that we, as a nation, have now reached the $2.6 trillion mark, consuming 17.9% of our GDP. Reaching that new mark required 3.9% annual growth vs. 3.8% in 2009. On the surface, the rate of growth seems less alarming than the insurance premium trends of 7%, 8%, and more that have been common year after year over the past decade. Yet the reality is that the changes are really like comparing apples and oranges, as the aggregate figures provided by HHS include a number of factors that mitigate the apparent modest rate of increase. Often, to really see where we are, we need to see where we were. In 1978, as I started my graduate studies in health care economics and finance, health care expenditures were approximately $250 billion in the U.S. I still remember my mother, a hospital nursing administrator, showing me the financial records of a hospital that could fit on one large table in approximately five large filing containers. There was already growth and complexity in health care compared even to the prior decade, but compared to today, it was a simpler, less expensive world, to be sure. So, now today, 34 years later, we have a health care economy that is 10 times that size.

Contributing Voices
Archelle Georgiou, MD

In 1995, Dr. Michael Rich published an article in the New England Journal of Medicine (NEJM) that fueled the start of an industry. In a randomized, controlled trial, he showed that an investing in proactive disease management (DM) activities could decrease the cost and improve the quality of life for patients with congestive heart failure.

The premise of disease management seemed intuitive:

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