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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 biggest for-profit and not-for-profit MCOs have been through rough times recently. How have their corporate cultures changed? Companies have separate identities, as distinct as you or me. Like us, they have histories. Events change them and, often, they influence events — especially if they are the two dominant players in their industry. The Kaiser … Read more

Coming into compliance with the requirements of the federal Health Insurance Portability and Accountability Act (HIPAA, the Kennedy-Kassebaum bill) of 1996 is a top legislative priority in a host of state capitals. Most states will have to change their existing market reform statutes to meet the requirements of the new law or face the possible … Read more

Insurers that charge higher copayments for less-useful treatments could improve care and save money, says a new study by Michael E. Chernew, PhD, a professor of health care policy at Harvard University. Chernew and colleagues propose an approach in which copayment rates are based on the value of clinical services (benefits and costs) — not … Read more

Physicians’ relations with practice management companies, accountants and other advisers may be significantly altered as providers come to grips with the federal government’s antifraud initiative. While most providers need to conduct an internal assessment of their compliance with billing rules and regulations, such an internal assessment would lead to a discussion that would result in … Read more

Your Disability Insurance: More Costly, More Needed The generous disability coverage that physicians are accustomed to is a thing of the past. Benefits have been trimmed and premiums increased. Doctors need to make sure they don’t lose this essential coverage. The Big Contradiction at Managed Care’s Heart Switching Doctors, Switching Plans: The ‘Revolving Door’ Problem … Read more

PALLIATIVE CARE Physicians don’t like to discuss end-of-life care. Neither do health plans, fearing it makes them look cold. A few plans are finding innovative ways to do it. John Carroll Contributing Editor Trained as a geriatrician, Minneapolis M.D. Edward Ratner had years of firsthand experience dealing with dying patients. But when his own daughter … Read more

Income levels expected by the nation’s new primary care doctors are still rising, according to a biennial survey of primary care residents completing their medical training, despite managed care’s reported downward pressure on physician earnings. This year’s survey also shows less enthusiasm for managed care than did the 1995 survey, and much greater preference for … Read more

November’s electoral surprise completely reshuffled the health care deck, but one card still came out on top: The Presidential oath is about to be taken by someone who is on record bemoaning pharmaceuticals’ lobbying power and criticizing drug prices. Candidate Trump talked of allowing drug imports and having Medicare negotiate drug prices, although he appeared … Read more

Who says the Clinton administration isn’t committed to using whatever forces and resources are necessary to wage war? When it comes to a domestic war against health care waste, fraud, and abuse, the administration isn’t pulling punches. Most industry experts will grant that the administration deserves some credit for gaining what could be considered major … Read more

Group Health Cooperative researchers say plans that provide full coverage of smoking cessation programs do so wisely. At $328 per person, they wrote in a Sept. 3 New England Journal of Medicine study, such programs are cheaper than hypertension and heart disease – which carry average annual costs of $5,921 and $6,941 respectively…. Highmark has … Read more

Minnesota-based HealthPartners works with local leaders in a successful initiative to improve health care in a developing African country. Scott Aebischer REACHING OUT It’s a lush, agriculture-rich land in the Great Lakes region of East Africa. Once a British colony, it is now a country of 23 million welcoming, beautiful people who are inspiring and … Read more

The authors of Understanding Value-Based Healthcare are respected clinicians and professors. Christopher Moriates, MD, of the University of California–San Francisco; Vineet Arora, MD, of the University of Chicago; and Neel Shah, MD, of Harvard Medical School quoted Donald Berwick, MD, an Obama era CMS administrator and founder of the Institute for Healthcare Improvement, as providing the rationale … Read more

January 2012 Keeping ED Costs Down an Exercise in Frustration Visits are going up and most cases seen in the ED are legitimate. What’s a payer to do? John Carroll Consumer-Directed Coverage Makes Market Inroads Those who choose these plans tend to be more educated and dedicated to maintaining healthy lifestyles Frank Diamond Cover Story … Read more

In general, salaries within managed care organizations are increasing to keep pace with market demands. Warren Surveys’ Spring 2000 Salary Survey concludes that the rise in salaries indicates that health plans are “keeping compensation at market levels, and understand that in a tight labor market a highly trained employee with managed care experience is a … Read more

Name Last modified Size Description Parent Directory 04-Jan-98 21:46 – MC9604.contents.shtml 16-Mar-97 22:45 3k MC9604.cover.jpg 16-Mar-97 22:45 14k MC9605.alternative.sh..16-Mar-97 22:45 12k ../../archiveMC/9605/MC9605.compmon.gif 16-Mar-97 22:45 20k MC9605.compmon.shtml 16-Mar-97 22:45 2k MC9605.contents.shtml 16-Mar-97 22:45 3k ../../archiveMC/9605/MC9605.disability.gif 16-Mar-97 22:45 9k MC9605.disability.shtml16-Mar-97 22:45 10k MC9605.editorsmemo.sh..16-Mar-97 22:45 3k MC9605.employer.shtml 18-Dec-97 10:59 9k MC9605.ethics.shtml 16-Mar-97 22:45 8k MC9605.leave_Medicare..16-Mar-97 22:45 8k MC9605.legal.shtml … Read more

Selecting the most appropriate medical insurance program may take a decent quantity of research. Knowing the association between yearly premium fees, deductibles and co pays has been near the peak of the list. Recently, knowing the type of medical care system an idea provides in addition has become crucial. A growing amount of carriers now … Read more

The FDA has issued a complete response letter for Digital Medicine (Otsuka Pharmaceutical/Proteus Digital Health), a drug/device combination product that combines the atypical antipsychotic drug aripiprazole (Abilify, Otsuka) with the FDA-cleared Proteus ingestible sensor embedded in a single tablet at the point of manufacture. In the new drug application (NDA) submitted by Otsuka and Proteus, … Read more

Picture a drug that has been compounded for decades and sold at a low price. The FDA approves a new formulation, and the price goes through the roof. Earlier this year, a controversy erupted after the FDA approved an injectable form of progesterone for preventing premature births. For decades, the medication had been sold by … Read more

Proponents of consumer-directed health plans (CDHPs) have a new study to cheer about: A retrospective claims analysis from a large employer that introduced a CDHP, a point-of-service (POS) plan, and a preferred-provider organization (PPO) to employees in 2001 found that the CDHP was cost-neutral or saved money on pharmacy compared with the POS plan and … Read more

State legislatures that tackle medical group insolvencies have come up with strategies that sometimes shift accountability to HMOs. In November 1999, Maryland surgeon Holuk Boneval suddenly found himself with 15 percent fewer patients, but not by choice. Boneval and some 400 colleagues belonged to Dimensions Health Network, a Maryland physician-hospital organization. Over the course of … Read more

By Lloyd M. Krieger, M.D., M.B.A. In the last election, Californians defeated ballot measures aimed at controlling the methods managed care plans use to limit health care. This took many by surprise. After all, the conventional wisdom went, California consumers were fed up with the excesses of some of their HMOs. Recent news accounts had … Read more

High demand, looser access controls, and greater provider clout are driving health care cost increases, according to an issue brief prepared by the Center for Studying Health System Change…. With demand for ER services on the rise, emergency physicians’ compensation is up sharply, according to Physician Compensation Report…. A William M. Mercer report finds that … Read more

Technology-Challenged Doctors Missing Out on Competitive Edge At the very least, patients could be directed to a web site where they download registration forms, complete them, and mail them to your office. The health care industry spends just under 2 percent of revenue on technology, compared to other industries’ 10 percent, and most medical offices … Read more

Online tools and an emphasis on patient-provider communication encourage more utilization of preventive medicine Aetna officials didn’t exactly cry “eureka!” when they released results of a study of their consumer-directed health plans, but they were proud of the results: Employers that replaced traditional PPOs with Aetna’s HealthFund plans saved $22 million over five years for … Read more

MANAGED CARE September 1999. ©1999 MediMedia USA The AMA has come out with its strongest condemnation of online prescribing, recommending that action be taken against physicians who prescribe based solely on a patient’s answers to an online questionnaire.The AMA contends that this practice “falls below a minimum standard of medical care.” State and federal agencies are paying … Read more

Surveys will begin in January for disease management organizations seeking the National Committee for Quality Assurance’s seal of approval. NCQA took public comment on its DM standards until July 31. Accreditation is offered to entities that pass a review of six areas: program content, clinical systems, coordination of care, patient self-management, practitioner support, and clinical … Read more

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. The Institute for Clinical and Economic Review (ICER), a small band of economists and health services researchers in Boston, is emerging as the nation’s go-to source for cost-effectiveness … Read more

First new asthma treatment in decades The first new asthma pill in decades has produced promising results in a small clinical study, potentially paving the way for another treatment option for patients by the end of the decade, according to a Reuters report. Researchers in the United Kingdom hypothesized that fevipiprant (Novartis), a prostaglandin D2 receptor … Read more

A Conversation With Mark Merritt This spokesman for PBMs urges Congress to learn from his industry’s experience in driving down costs Working for an industry built on cutting health care costs gives Mark Merritt, president and CEO of the Pharmaceutical Care Management Association, a perspective valued by Washington D.C. policymakers these days. The association represents … Read more

Raising copayments in tiered prescription drug plans increases the likelihood that patients will stop taking prescribed medications, according to a recent study published in the New England Journal of Medicine. The study followed two employers as they changed their prescription coverage plans in 2000. Employer A switched from a plan without tiers to a three-tier … Read more

The U.S. Food and Drug Administration Now Published a warning Hint Into Alkermes, Inc. of Massachusetts, to get misbranding the medication Vivitrol (an extended-release injection formula of naltrexone) by expressing warnings in regards to the very serious risks connected with the medication from promotional substances. Vivitrol is qualified for preventing relapse to opioid addiction, after … Read more

CPT and ICD-9 codes are being used to select candidates for disease management programs. Are they the right tools for the job? Rick Hassett, medical director and vice president for medical affairs at Accordant Health Services in Greensboro, N.C., is no stranger to the pitfalls of using claims data to create disease management programs. His … Read more

Observing a 17 million settlement earlier this Season, Aetna has Consented to cover three countries almost $650,000 to fix investigations into A-2017 episode in that it revealed associates’ HIV status.In Another event two weeks afterwards, Aetna sent letters to 1,600 individuals in regards to a report for patients who have atrial fibrillation, unintentionally showing their … Read more

Beware of the spillover effect regarding the endorsement of 12 measures for coordination of care last month by the National Quality Forum. The measures focus on areas such as medication reconciliation, proper use of the ED, and timely initiation of care. “The NQF has a special line to/relationship with Medicare, so anything recommended by NQF … Read more

They’re young, they’re hungry, and they claim to be approaching business problems from a different angle. Will these entrepreneurs succeed? 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 advances in medical … Read more

You would not be reading this if not for “disruptive innovation” or “disruptive technology,” terms that serve as this issue’s theme. In the magazine business, a disruption called desktop publishing years ago killed jobs, mostly typographers, pressmen, and proofreaders, while reducing costs and allowing many more editorial voices to be heard. As survivors of that … Read more

What Do Patients Really Think of Managed Care? Opinion surveys on all sides these days purport to prove that patients like–or don’t like–what they’re getting with managed care. A health survey specialist at Harvard makes sense of the conflicting headlines. Payoffs for Physicians When They Go ‘Online’ Is it worthwhile for even a computer-shy physician to spend … Read more

First advance in therapy for soft tissue cancer in decades   July 21, 2016 Adding a novel monoclonal antibody therapy to traditional chemotherapy increased median survival by nearly a year in patients with advanced sarcoma, a lethal soft tissue cancer. Findings from a multicenter clinical trial of the combination therapy, led by researchers at Columbia … Read more

Dwindling of Employer Plans Would Reshape the Industry Analysts predict the change may save businesses $3 trillion and add to health plans’ risk business, but others doubt that big employers will willingly cede their health insurance role Will the Affordable Care Act (ACA) sound a death knell for employer-sponsored health care? Analysts at Standard & … Read more

Over the next three years, more than 80 percent of drug costs will be concentrated in seven therapeutic categories, according to Medco Health Solutions. However, drugs for the central nervous system and endocrine/diabetes drugs will account for almost 40 percent of spending growth. “Pharmacy directors at health insurance plans can develop more effective plan strategies … Read more

Many who claim to be constructing such entities are really creating ‘clinically integrated organizations’ Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD Scott Guerin, PhD Organizations that are not aligned with the definition of an ACO can be more accurately described as clinically integrated organizations (CIOs). The major difference between the two is that true … Read more

POLITICS OF CARE Proponents tout personalized care and easy access, and imply superior health care. Critics fear “elitist”practices. Sharon Baker Hailed by some as an antidote for doctors frustrated with managed care and reviled by others as an elitist practice that benefits only the rich, retainer medicine is generating heated discussions across the country. In … Read more

Next year’s proposed 10 percent cut in Medicare payments is serving as a rallying point for members of the American Medical Association, which says the cuts will make it difficult for physicians to accept new Medicare patients. “The baby boomers begin entering the program in 2010, and the Medicare cuts increase the likelihood that there … Read more

Ruling on queries from phone banks, working to end hospital errors, meeting with disgruntled physicians: Does any of this sound familiar? The first thing you notice about Ronald Brooks, M.D., is your second surprise of the day. Brooks, a network medical director for Aetna U.S. Healthcare, has agreed to let you follow him around so … Read more

Some Health Insurance Plans Groan About Not Making It on Exchanges UnitedHealthcare, Aetna, and Humana all lose money, but Cigna’s CFO says that’s just the price for getting started in a new market.   Updating what’s going on with the ACA exchanges these days is a little like giving weather reports; predictions have a shelf … Read more

It’s crucial to understand what constitutes medical uncertainty. An physician prescribes particular duties to the individual that consults him to get disease. A lack in this obligation ends in negligence. A fundamental understanding of medical neglect will be adjudicated within the many juvenile courts of India may enable a health care provider to practice his … Read more

Online bill payment is the new norm, report finds   With rising health care costs and higher health insurance deductibles, hospitals could find themselves in trouble with patient bad debt if they don’t make improvements in collecting out-of-pocket payments, according to an article in HealthData Management. The Boston-based Aite Group predicted that patient payments to hospitals … Read more

When Aetna U.S. Healthcare and Texas’s attorney general settled a lawsuit over financial incentives last month, the AMA viewed it as an improvement in Aetna’s physician relations. However, if the Texas deal ignites a trend away from the use of incentives to keep utilization down, then some capitated physicians worry it will put them in … Read more

A Cartoonist’s Take on Managed Care “How often do you have this pre-existing condition?” “I’ve been under a lot of pressure to get well.” “I’m putting you on a stronger placebo.” “The technology’s in place. Now all we have to do is misuse it.” “I’m softening my position on the spending binge the doctors have … Read more

BY FRANK DIAMOND Senior Editor HMO executives trying to encourage physicians to follow clinical practice guidelines sometimes sound like parents trying to persuade their teenagers to tidy up a bedroom. “What we’ve got here,” as the warden said in Cool Hand Luke, “is a failure to communicate.” Just talk to John Wallendjack, M.D. As vice … Read more

EDITOR’S MEMO 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 … Read more

EMA’s human drugs committee (CHMP) has advocated awarding a promoting authorisation from the European Union (EU) to get Sixmo (buprenorphine) because of substitution treatment for opioid addiction. Sixmo Is a enhancement that releases low degrees of buprenorphine in to your individual’s body to get a few months. It’s suggested in clinically obese adult patients that … Read more

Expanded Medicare coverage for obesity is the result of the government’s removal of language from the Medicare manual that states that the condition is not an illness. Although the Department of Health and Human Services stopped short of calling obesity a disease, the move will give Medicare leverage concerning what can be covered. “With this … Read more

Frequently, when folks desire to better their financing, they lower your expenses or even increase their income. An map from the Monetary Foundation indicates still another exceptional method to enhance your bottomline: Proceed to a location where your dollar goes farther. The chart below shows the true purchasing power of 100. At one extreme Is … Read more

Southerners are 77 percent more likely to fill a prescription for a stimulant, 46 percent more likely to fill one for an antidepressant, and 42 percent more likely to fill one for an antipsychotic than people in the rest of the United States, according to a study by Yale University researchers. The study looks at … Read more

 About this capture Skip to Main Content Area MANAGED CARE August 2012. ©MediMedia USA NEWS & COMMENTARY Informal Physician Ties Forge Stealth ‘Networks’ The age of health reform places increased emphasis on pro­viders, and it might behoove insurers to find the informal ways that some physicians are connected. Often doctors have “a history of working … Read more

Generic drugs are being dispensed in doctors’ offices by devices that function much like automatic teller machines that banks use, under a program sponsored by Blue Cross Blue Shield of North Dakota. What the company is calling its Generic Delivery Network has been launched in physician offices in Fargo and Grand Rapids with the aim … Read more

With acquisition costs so low, pharmacies are almost giving away generic statins. How this affects the structure of the pharmacy benefit is yet to be determined. Tom Reinke In its heyday, Lipitor had caché. It was the Gucci or Coach of statins: Patients asked for it by name and physicians loved to prescribe it. It … Read more

LEGISLATION & REGULATION Sovaldi Dilemma Likely to Get Worse Analysts say new competition in the hepatitis C market may not offer lower prices. And Gilead is preparing a higher-cost Sovaldi treatment. John Carroll Three years ago, Vertex had the hottest drug launch in the biopharma industry as it rolled out telaprevir (Incivek), a new standard … Read more

Oncologists may no longer mark up the cost of specialty drugs. If the plan works, you can bet that other insurers will adopt something similar. Joseph Burns By the end of this year, UnitedHealthcare will be reviewing data from five oncology groups to determine whether a pilot payment program for cancer care should be expanded. … Read more

With Misuse of opioid painkillers That a Significant public health Hazard from the United states of america, lots of stress that jelqing utilization could trigger dependence. However, A brand new study implies that pain killer misuse appears in just a tiny percent — less than 1 / 2 a per cent — of cases between … Read more

Results from a phase 3 study evaluating the efficacy and safety of biosimilar ABP 980 compared with trastuzumab in patients with human epidermal growth factor receptor 2 (HER2)-positive early breast cancer have ruled out inferiority compared to trastuzumab but could not rule out superiority based on its primary efficacy endpoint: the difference of the percentage … Read more

When drug manufacturer coupons make members’ costs for brand drugs equal to generics — or less — health plans, employers, PBMs, and members pay a price Health plans that are trying to control their prescription coverage costs must act as if they are engaged in the game of whack-a-mole: They must be continuously ready to … Read more

‘Young Invincibles’ Want Coverage Frank Diamond Everybody else always knew that they weren’t really invincible, and now they seem to be grasping that fact as well. More than 70% of people 30 and younger say that having health insurance is very important to them, according to a poll by the Kaiser Family Foundation (http://tinyurl.com/insured-youth). These … Read more

For the first time, the National Committee for Quality Assurance says it can demonstrate a strong link between clinical quality, as reported in HEDIS, and member satisfaction. Plans that scored in the highest quartile last year on “effectiveness of care” measures in HEDIS, NCQA’s vehicle for HMO-quality measurement, also received the highest marks from members … Read more

The search for an acceptable oral MS drug may be over if fingolimod (Gilenia) survives an FDA review this fall Thomas Morrow, MD A head-to-head trial pitting the pioneer multiple sclerosis (MS) drug, Avonex, against an investigational oral product demonstrates that an oral product is superior to both placebo and Avonex for those suffering from … Read more

Public fascination with alternative medicine gives health plans a can’t-miss business opportunity. Science may determine whether plans’ interest lasts. JUMP IN NOW, ASK QUESTIONS LATER Anyone who thinks he is having a flashback, raise your hand. The popularity of alternative medicine has a 1960s feel to it: natural products, an interest in Asian practices, a … Read more

Mark D. Abruzzo, J.D. There are approximately 2,600 ambulatory surgery centers in operation in the United States. A great number are entirely or partly physician-owned, but many others are owned, in whole or in part, by hospitals or health systems or by corporate chains. Given the present trends and incentives in the medical arena, we … Read more

Managed care is a topic that’s hard to avoid even in one’s casual reading. In “The Doctor’s Office,” a regular column that appears in the Wall Street Journal, Benjamin Brewer, MD, laments the changes in his profession. The complaints will sound familiar to readers of this publication as, for instance, when Brewer states that “Somewhere … Read more

One of the key downsides of market-based health care — that if your costs regularly exceed your income you go out of business — is not typically associated with the National Health Service in the U.K. That is about to change. It has just been announced that the three hospitals that constitute the South London … Read more

“Until Gleevec came 15 decades past, patients using complex GISTs faced a lifetime span of 18 weeks. Now we’ve heard that a few could live a little while or even more. And we’ve begun to comprehend which kind of patients reap the most from Gleevec.” Out of SWOG, the global cancer research community encouraged by … Read more

Modelling traveling time to services is now a standard public health program for preparation service supply however, also the usefulness of those diagnoses is restricted by the availability of accurate input and limits inherent in the premises and parameterisation. That is especially a concern in the developing world where use of basic data is bound … Read more

West Virginia Gov. Cecil H. Underwood last month unveiled a disease management program to control Medicaid prescription drug costs. The governor chose the new program instead of a formulary, which a study group he appointed had proposed. The National Pharmaceutical Council, a not-for-profit organization funded by a group of drug manufacturers, will provide $500,000 for … Read more

Head Off All the Risks in an Acquisition Tom Ewers and Munzoor Shaikh of West Monroe Partners discuss the ins and outs of pre-close integration planning for health care payer mergers and acquisitions. The M&A process should begin by clearly defining both the acquisition strategy, type of acquisition (Leverage Business Model (LBM) or Re-invent Business … Read more

Aetna is unveiling something it calls the Medicare Open Plan, targeted for employers who want to offer retirees age 65 or over a fee-for-service Medicare Advantage plan. If CMS approves, Aetna hopes to launch the plan in January 2007…. A consumer-directed effort by Tufts Health Plan hasn’t planned out the way management had hoped. Tufts … Read more

Moving esomeprazole (Nexium) to the third tier of the Tricare formulary and subsequently raising its copayment from $9 to $22 for a 30-day supply resulted in a 25-percent reduction in the number of prescriptions filled in the month after the change, according to research published in the January/February issue of the Journal of Managed Care … Read more

MANAGED CARE June 2009. ©MediMedia USA Health insurance plans’ net income plummeted 36 percent in 2008, according to a recent report by Mark Farrah Associates, a consulting company. The company cites — what else? — the recession and market turmoil. While overall revenues increased 6.2 percent, from $270 billion in 2007 to $287 billion in 2008, profit … Read more

Washington Initiatives No bloody firefights or government closings were expected as members of Congress got to work on fiscal year 1998 funding bills after their August recess. Most of the issues, in fact, had been settled by the House andSenate appropriations committees during the summer, but were tabled by a flareup over prohibiting abortions under … Read more

TOMORROW’S MEDICINE Treatments that interfere with protein synthesis at the cellular level will soon be debated in medical policy committee meetings. Thomas Morrow, MD In my travels around the country, I find that most pharmacy and medical directors are having a difficult time keeping up with all of the newly released products in the pharmaceutical … Read more

Over 100 years after they were Identified, two menacing sign posts of Alzheimer’s disease (AD) remain fundamental issues of research both formed by tacky accumulations of protein from the brain. Amyloid-beta divides in to senile plaquesthat leads from the extra cellular spaces of neural cells, whilst tau protein creates neural forms ridding the entire body … Read more

For now, consumers are willing to pay extra for direct access. How long that continues is linked to whether old practice habits can be broken. The specialist is certainly becoming more special these days, perhaps soon to be included with the spotted owl and plains buffalo as one of our endangered species. A recent Forbes … Read more

The man viewed by many physicians as a poster boy for health plan greed — Aetna U.S. Healthcare CEO Richard Huber — was forced into early retirement as shareholder criticism of his leadership mounted. Aetna’s stock price was near its 52-week low Feb. 25 when Huber resigned under pressure. Aetna faces a number of issues … Read more

El Paso First Health Plans did not lose sight of the two goals in the overhaul of the electronic data interchange system Managed Care Staff In the real world, companies don’t have the luxury of taking on challenges one at a time, and a Medicaid health plan in Texas used that reality to get ahead … Read more

Managed care companies that say they are becoming more responsive to members will want to pay attention to consumer attitudes reflected in a Kaiser Family Foundation survey of health plan members. Most consumers, whether enrolled in a managed care plan or fee-for-service coverage, give their health plan a grade of B or higher, but many … Read more

Health plans can offer several kinds of assistance to physicians who are having trouble caring for these patients Bob Kirsch It is not for every illness that the FDA recommends massage and emotional support. But fibromyalgia is not like most other illnesses. First, it should be said that there is no longer any question about … Read more

A quality incentive program in California is yielding results that could be replicated in Medicare and other pay-for-performance (P4P) programs nationwide, according to “Advancing Quality Through Collaboration: The California Pay-for-Performance Program.” The report was issued by the program’s sponsor, the Integrated Healthcare Association (IHA), a collaboration of California health plans, physician groups, and hospital systems. … Read more

COVER STORY ‘Population-Based,’ Meet ‘Patient-Centered’ Two vaunted ideals of health care, experts say, should be perfectly aligned. And they almost are. Timothy Kelley How To Combat Pharma’s Costly Coupon Programs When drug manufacturer coupons make members’ costs for brand drugs equal to generics — or less — health plans, employers, PBMs, and members pay a … Read more

The need for health plans to cut administrative costs is hammering insurance brokers. Is this another instance of the law of unintended consequences? A few months ago, the Government Accounting Office polled a group of insurers around the country about the effect that the new medical loss ratio rules were having on health plans. The … Read more

Other countries have demonstrated the benefits of a national tracking and monitoring registry for surgical implants, but the United States has been lagging. Now a medical device registry set up by Kaiser Permanente that tracked 85,000 joint surgeries is helping clinicians provide better care and lower costs, as the incidence of replacing the devices can … Read more

United HealthCare’s move to make advance authorization “obsolete” generated headlines. Inside the industry, however, the reaction was muted. By Steve Heimoff When United HealthCare announced in early November that it is making preauthorization “obsolete” so that physicians apparently will no longer be required to gain plan approval before providing hospitalized patients with medical services, the … Read more

A summary of ECRI Institute’s Emerging Technology Evidence 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 the Institute’s Emerging Technology Evidence Reports. ECRI Institute is an independent nonprofit organization that researches … Read more

High-Tech Drug Packaging Can Boost Patient Compliance Sometimes you have to spend money to save money. Vials with microchips, beeping blister packs and other new pharmaceutical delivery media, even if they are a bit pricey, could lower overall health care costs. Can Health Plans Change Unhealthy Behavior? Smoking, fat-filled diets, endless gazing at the tube … Read more

HEALTH PLAN 2009 Helen Darling Helen Darling is president of the National Business Group on Health (until recently, the Washington Business Group on Health). The group’s members are 185 of the nation’s largest private and public sector employers representing about 40 million workers, retirees, and their families. By 2009, there may at last be a … Read more

MANAGED CARE May 1999. ©1999 Stezzi Communications Fewer than 15 million Americans buy their own health insurance. That’s only 5 percent of the population, but states continue to struggle with issues of access and affordability in the individual market. In contrast to group insurance, the individual market is a high-risk proposition because a disproportionate number of these … Read more

The Food and Drug Administration has declared Nucala for its treating adults using eosinophilic granulomatosis using polyangiitis, a rare autoimmune disorder which creates vasculitis. This approval marks the very first medical treatment method for EGPA. “Ahead of the current actions, patients using this particular ambitious, infrequent disorder failed to possess an injectable treatment alternative,” explained … Read more

After years of stagnation, organ donations are up, and organizations that collect organs for transplantation and the hospitals they work with say their partnerships have been the key to getting the numbers to grow, according to an article posted on the HealthLeaders Media website. The number of organs from deceased donors rose 5.6% in 2015 … Read more

The study results are a mishmash; the methods, a work in progress. Antibiotic prescribing is a trouble spot. Antibiotic overuse? Ateev Mehrotra, MD, of Harvard Medical School, found that primary care physicians were more inclined to prescribe antibiotics for sinusitis and urinary tract infections when they performed an e-visit compared with patients they saw in … Read more

The dollar amounts have changed and so have the cities, but California is still the golden state to be a pharmacist. The federal Bureau of Labor Statics (BLS) provides a list of the top four employment and wage figures for pharmacists, calculated from employers in all industry sectors in metropolitan and nonmetropolitan areas in every … Read more

The National Committee for Quality Assurance, in its never-ending effort to improve its own quality, wants to expand what the committee’s Healthcare Effectiveness Data and Information Set (HEDIS) measures look at in 2009. As part of what the NCQA calls its “effectiveness of care” measure, the committee will review how well health plans immunize adolescents. … Read more

Since Hippocrates, physicians have been perpetually plagued by concerns over whether patients continue to take medication as prescribed — or at all.1 Many methods attempt to identify adherent behaviors, methods that range from patient and physician surveys to microprocessor-chip technologies on medicine containers.2 Most, if not all, of these approaches provide only a modicum of understanding … Read more

Pennsylvania has been one of the states hardest hit by the opioid epidemic, with more than 3,500 people dying from the drugs last year. Michael Ashburn, MD, MPH, guest blogs today on the Philadelphia Inquirer’s health section and points out that the epidemic started with the best of intentions: relieve pain. Ashburn blogs: “Over the years … Read more

The country’s catastrophic economic situation shrinks coverage, closes hospitals, and cuts physicians’ salaries — and that might be just the beginning London — The financial crisis that engulfed much of the world from 2008 onward had a significant impact on Europe, to the point where it can be regarded as the dominant issue for most health … Read more

Convenient care clinics, as they like to be called, are spreading quickly because members and plans like them In the past 12 months retail clinics have spread like a rash over the health care landscape — the kind of rash they can easily treat in 15 minutes or less, for around half the cost of … Read more

BY NEIL CAESAR, J.D. It is important for a medical group’s internal structure and inter-physician documents to be updated to reflect the realities of managed care. Let’s examine, for example, the departure of one of the group’s physicians. Say that physician is not retiring, but is withdrawing from the group because of disagreement over the … Read more

Health plans know that getting along with physicians is important, and many are trying new initiatives. Here are some successes. Michael D’Eramo has very positive things to say about Anthem Blue Cross and Blue Shield. And that may surprise some people, because D’Eramo doesn’t work in the human resources department of a large corporation that … Read more

A baseline report issued by the National Business Coalition on Health called the “eValue8 Cornerstone Report: Measuring the Success of America’s Health Plans” finds that price transparency is still in its infancy and that there is a wide variation in plan performance when it comes to promoting transparency, care improvement, and information technology. The variation … Read more

A recent proposal to create a council that would oversee insurance nationally would affect health insurers, but mostly in the areas of long-term care and disability, according to one expert. The concept, broached recently by Michael Oxley, a Repub-lican congressman from Ohio, would force states to adopt uniform standards and permit the marketplace to determine … Read more

Widely utilized to appraise primary healthcare operation, since the hospital entrance might possibly be prevented if maintenance was fair and timely. Internal evidence suggests that avoidable hospitalizations take a significant direct financial lack in a few nations. But no attention was directed at the financial burden on society that they represent. Direct costs were got … Read more

Approximately 250,000 People in the U.S. Live with PI ADMA Biologics, Inc. has received FDA approval for Asceniv™, Immune Globulin Intravenous, Human–slra 10% Liquid, previously known as RI-002. The intravenous immune globulin product is for treatment of primary humoral immunodeficiency disease (PI) in adults and adolescents aged 12 to 17 years. Asceniv Immune Globulin Intravenous, … Read more

Washington Initiatives Rep. Charles Norwood, the Georgia Republican, has introduced legislation that would amend the Employment Retirement Income Security Act in a way that would benefit employers but spell bad news for plans. The Responsibility in Managed Care Act closes a loophole in ERISA, which has shielded health plans from medical malpractice lawsuits. We’ve seen … Read more

Halaven Injection for treating patients with unresectable or metastatic liposarcoma who’ve gotten a prior anthracycline-containing chemotherapy regime. Halaven is really a microtubule dynamics inhibitor using another binding profile which exerts its effect with a tubulin-based anti-mitotic mechanism, eventually resulting in apoptotic cell death after protracted and long-term mitotic blockage. Halaven is currently currently approved for … Read more

Mistakes can result from poor design, study finds Spurred by the 2009 stimulus package and the 2010 Patient Protection and Affordable Care Act, the federal government has offered hospitals financial incentives to adopt electronic health records (EHRs), which are expected to add efficiency and reduce errors by linking physicians’ patient records, and by coordinating and … Read more

And Drug Administration approved Gazyva® in conjunction with chemotherapy, followed closely by Gazyva alone in people that reacted, for individuals who have previously untreated advanced follicular lymphoma. Follicular lymphoma, probably the most frequent slow-growing type of non-Hodgkin lymphoma, is incurable and becomes even tougher to take care of everytime that it returns. “Now’s Gazyva acceptance … Read more

Medication safety can be seen as a global concern requiring close collaboration Thomas Reinke 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 … Read more

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The inability of President Bush and Congress to come to terms on such hot-button health care issues as HMO liability and Medicare drug coverage has helped to push another topic to the fore: the availability of generic drugs. Bush on Oct. 21 proposed a regulation that reduces the amount of time that patents can protect … Read more

The good news for payers: Health care spending is estimated to have grown 7.8 percent in 2003, a slowdown from the 9.3 percent growth seen in 2002. The good news for providers: During the next 10 years, health spending growth is expected to outpace economic growth, with the health care portion of the gross domestic … Read more

The vicious terrorist attacks on the World Trade Center and the Pentagon have, appropriately, refocused the government’s attention on a coordinated response. And though President Bush has pledged to be a faithfulsteward of the country’s business while directing the war against terrorism, nobody is predicting that what had been pressing health care issues before Sept. … Read more

charts For the first time in 10 years, the drop in behavioral health coverage, as a percentage of total employer-sponsored health benefits, has leveled off. But the amount of money the typical employer spends on behavioral health benefits continues to decline. For outpatient care, fewer plans are imposing per-visit dollar limits, but more are placing … Read more

Wellness When it comes to encouraging wellness programs, government is starting to get into the act. On Capitol Hill and in statehouses from Maine to California, legislators are sponsoring measures to encourage private sector employers to embrace wellness programs as one way of clamping down on health care inflation. At the federal level, Republican Rep. … Read more

Hammurabi’s Managed Health Care — Circa 1700 B.C. Allen D. Spiegel, Ph.D. The roots of modern managed care go back to prepaid health plans of the 19th century, but many of the concepts we use today were embraced in ancient times. The Babylonians had a system with many parallels to the present one. MANAGED CARE May 1997. … Read more

Type Title Author Story Negotiations for 2002 Could Yield 15 Percent Increase in Premiums webadmin Story Report: Physicians storm Web sites to get information on formularies webadmin Story Among specialties, family physicians’ pay seems to weather managed care best webadmin Story Doing the Right Thing For Employers and Members webadmin Story Employers’ Institute To Fight … Read more

Nearly 50 percent of members report that they don’t fully understand how to use their health insurance coverage and member services, according to the J.D. Power and Associates 2008 National Health Insurance Plan Study, which measured member satisfaction with 107 health plans in 17 regions through the United States. Members were surveyed on seven key … Read more

Reaping What Mergers Sow: How To Prepare for Bankruptcy Many health care organizations that had reached for the brass ring are now wringing their hands as they file for Chapter 11. All is not lost, however. Keith J. Shapiro ; Nancy A. Peterman 3 Health Care Startups Refuse To Be Boxed In They’re young, they’re hungry, and … Read more

Meaningful Use Standards Not Being Met Forty-four thousand dollars is certainly a meaningful amount of money to me, but apparently not so meaningful as to encourage a sizeable portion of physicians to adopt meaningful use standards for electronic health records. “As of May 2012, a total of 62,226 eligible professionals had attested to meaningful use … Read more

Is it worthwhile for even a computer-shy physician to spend a little time investigating the Internet and other online services? You bet it is. Here are some of the ways these resources can work for you To a technophobe, “cyberspace” may seem as foreign the surface of Mars, and almost as threatening. But if you … Read more

Writing in the Wall Street Journal, attorney James Lieber has suggested five ways to reduce medical mistakes, which account for 250,000 deaths annually in the United States. Lieber is the author of Killer Care: How Medical Error Became America’s Third Largest Cause of Death and What Can Be Done About It (OR Books, 2015). His suggested … Read more

Chart pages from MANAGED CARE Plastic surgeons ask: What recession?   How much return does that PhD provide?   Pharmacists test payment model based on outcomes   Payers: Expect to feel a double-team pinch   Productivity continues to outpace compensation   School debt can be significant in primary care   California still golden for pharmacists … Read more

Two trends are apparent in the National Committee for Quality Assurance’s annual report on health plans. In the eyes of the organization, here’s the bad trend: The rise of consumer-directed health plans, which do not yet measure and report on quality. Only about 21.5 percent of the industry reports publicly on its performance. (For more … Read more

Not everybody believes that accountable care organizations (ACOs), a bulwark of the Affordable Care Act, will ride to medicine’s rescue. In fact, in these pages, well-known policy experts such as Regina Herzlinger, PhD, of Harvard Business School, and David J. Brailer, MD, PhD, the health technology czar under President George W. Bush, have been downright … Read more

The international Platform for mobile telecommunication Has been made in 1982 in Europe with a view of supplying a increased messaging platform. The exact first use of cell mobiles in India continues to be around 1995; today you will find 287 million mobile users in India, that constitutes roughly 85% of users.1 Nowadays, most cellphones … Read more

The National Association of Insurance Commissioners has spent two years developing a model. Drug companies like it; health plans don’t. The development of model laws and regulations is one of the main functions of the National Association of Insurance Commissioners, which has generated hundreds of them. Almost two years into the drafting of a model … Read more

Small-business owners in Michigan have released a survey that they hope will prompt legislation to prevent some health insurers from — in the business owners’ words — “overpricing” policies. According to a random survey of 300 small-business owners, 25 percent think rising premiums threaten their ability to stay in business. The Small Business Association of … Read more

Otezla, Warts and All, Racks Up Sales and Eyes Blockbuster Status Varying treatment strategies for a highly variable disease have given the new drug an opening—and, besides, it does OK when it comes to QALYs. Otezla was approved by the FDA in 2014 as a treatment for plaque psoriasis and psoriatic arthritis. Right out of … Read more

Salaries for staff pharmacists saw a healthy jump of 5.5 percent in 2005, compared to 2004. Median income for all Americans remained stable between 2002 and 2003, according to the latest figures available. The salaries of pharmacy team managers, staff pharmacists at mail order/online pharmacies, and clinical pharmacists, were collected and collated by Mercer Human … Read more

A new model of care developed by the American Academy of Family Physicians places primary care physicians back at the center of care delivery Martin Sipkoff Contributing Editor Primary care physicians have long complained that they suffer at the hands of health plans. What they see as inadequate payments and their belief that plans want … Read more

Health plans play a key role in data quality and will benefit from improvements Thomas Reinke E-prescribing is growing rapidly, according to Surescripts, an intermediary that routes prescriptions from prescribers to pharmacies, but this technology faces important challenges in streamlining work flows and producing high-quality data. Experts at the American Pharmacists Association (APhA) cite problems … Read more

Medicare considers going beyond palliative care, and Aetna finds that allowing curative treatment and loosening admission criteria reduce costs and improve quality of life Medicare has been credited with a wide range of payment innovations that were later embraced by private health plans, but when it comes to benefit design, most experts think of private … Read more

In Henderson, Texas, 11 physicians at the local hospital have the distinction of being the first group to come together under a state law, gain certification as a bargaining unit, and approach a managed care company to negotiate pay. They never even got to shake hands. Blue Cross and Blue Shield of Texas refused to … Read more

The proportion of Americans reporting treatment for diabetes who took oral medications to treat their condition rose from 60 percent in 1997 to 77 percent in 2007 — a 28 percent increase. During that period, the proportion taking insulin to control their diabetes fell from 38 percent to 24 percent, according to the Agency for … Read more

First light Patterson keeps a multimillion-dollar drug in the cooler, close to a container of root lager and a container of salsa. The medication, Strensiq, treats an uncommon bone illness that tormented her with horrifying torment and left her battling to work or really focus on her family. A year after she started taking the … Read more

U.S.-based Health insurance Cigna Corp and Aetna Inc have encountered handles Novartis AG to get a lump-sum cost for its Swiss drug maker’s brand new heart medication, Entresto, ” the organizations said on Monday. The Agreements are one of the couple performance-based deals which were made public by drug makers and U.S. managedcare organizations, which … Read more

Insurer and provider come together to deliver primary and specialty care in 20 clinics. The joint venture blurs the line between stakeholders. Will patients benefit? In June, Blue Cross Blue Shield of Minnesota and North Memorial Health, a health care system anchored by a 353-bed hospital in suburban Minneapolis, announced that they were forming a … Read more

Increases partly fueled by facility fees Chances are that outpatient chemotherapy treatment costs are higher if a patient’s oncologist works for a health care system than if the physician has his or her own practice, according to a study by researchers at the University of Chicago. The team analyzed private health-insurance claims data from the … Read more

Diabetes Could Be Managed Care’s Big Chance The industry will never get to bask in do-gooder glory. But complications from diabetes are down. Programs targeting prediabetes are working. We know what to do, a top doctor declares. Now is the time to organize delivery to do it. Timothy Kelley Medicaid Prepares to Shoulder Diabetes Burden … Read more

A review of outcomes data for Medicaid participants enrolled in managed care organizations (MCOs) suggests that financial incentives may affect the preventive care that primary care physicians (PCPs) provide to enrollees. The lead author, Troy Quast, PhD, an assistant professor of economics at Sam Houston State University in Huntsville, Texas, and other researchers compared two … Read more

Although sales of all medical imaging products are projected to increase 6 percent to $21.4 billion in 2010, overall growth beyond that point will slow, according to a new report. Sales of computed tomography (CT) scanners, magnetic resonance imaging (MRI), and positron emission tomography (PET) equipment have been growing 6.8 percent annually since 2005. Future … Read more

John Marcille Humor depends on truth, and a funny sequence in a currently running situation comedy involves a television executive making a cameo appearance on one of his shows. Suddenly, reflexive actions become an amateur actor’s overdone gestures. When he “walks” into the scene, he resembles the just oiled Tin Man in The Wizard of … Read more

Color chart The news that national health expenditures rose a modest 4.4 percent in 1996 is not likely to be repeated, according to a new estimate by Milliman & Robertson. Though M&R does not foresee an immediate return to the days of double-digit increases, its 1997 – 2000 health spending forecast predicts a moderate rise, … Read more

There is no one-size-fits-all contract, says a senior executive at Prescription Solutions. A PBM can perform many functions. Over the past decade, a growing number of managed care organizations have come to view pharmacy benefit management companies as more than just vendors or sources for purchasing discounted drugs and administering claims. As health care continues … Read more

SYSTEMS & SOFTWARE Some of the same technology that has been transforming American business may soon be changing physicians’ offices and clinics. Several companies are now marketing products and services designed to streamline the management of medical practices. These new offerings are based on combinations of three technological advances over the past decade: the Internet … Read more

MANAGED CARE OUTLOOK Hepatitis C meets its match Exciting news about treating hepatitis C (HCV) keeps on coming. For instance, it could be classified a rare disease by 2036 (and, in a best-case scenario, by 2026) thanks to new therapies and more aggressive treatment, according to a study in Annals of Internal Medicine. ‘Recently approved … Read more

Within a few years, there may be only 30 DM companies left, says one expert. HMO customers want vendors to handle more than one condition.At the time L. Peter Smith jumped into the disease management field six years ago, prospective customers in managed care had a simple expectation: Prove what you’re pitching. By establishing protocols … Read more

BY 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 … Read more

Clinical trial sponsor it had violated regulations requiring which results in human studies of health care treatments and apparatus have been posted into the national repository ClinicalTrials.gov. The activity had been pitted from the Cambridge, Massachusetts–established medicine business Acceleron Pharma because of the failure to supply data out of the completed trial of its experimental … Read more

More on the pay-for-performance push. MedVantage, a consulting company, says that more such programs (42 percent) are now aimed at specialty care. But physicians are wary. “There are a lot of established markers for quality care in our specialty, but often even in those, there is disagreement,” Ronald Vender, MD, a partner at the Gastroenterology … Read more

Few weeks go by without someone touting the benefits of a new genetic test. Such innovation is needed, of course, except when it overwhelms our ability to vet these developments. Yet that’s already happened. Health plans can’t keep up with orders from physicians for new complex molecular diagnostic tests that clinical labs develop and promote … Read more

Executive order means that Medicaid insurers are at the mercy of the state for determining what drugs to purchase to get best pricing. California Gov. Gavin Newsom wasted no time taking on one of the hot-button issues in health care, the skyrocketing costs of drugs. On Monday, the same day he was sworn in, Newson … Read more

A sweeping proposal for improving veterans’ health care would use the Kaiser Permanente model of separating the insurance and payer arms of the Veterans Health Administration (VHA), making the provider an accountable care organization (ACO) and allowing vets to purchase insurance from consumer plans. Concerned Veterans for America, a bipartisan policy taskforce that is pushing … Read more

For-profit insurers will evolve by developing lines of business beyond health insurance, predicts Wendell Potter, an author and former insurance company communications executive. “I don’t see insurers going out of business,” says Potter, the author of Deadly Spin, An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans (Bloomsbury Press, … Read more

FDA is slow to respond At least 250 people, mostly in the U.S., developed life-threatening “superbug” infections linked to contaminated medical scopes during the past three years — more than previously estimated by federal regulators, according to a new report from the Senate Health, Education, Labor, and Pensions (HELP) Committee. The report was the result … Read more

The belief that Medicare is a more efficient system than employee-sponsored health insurance comes under fire in a study that claims there are hidden costs in the government program. “One of the most common, and least challenged, assertions in the debate over U.S. health care policy is that Medicare administrative costs are about 2 percent … Read more

Drug Cost-Sharing Amounts Stable 2010 to 2011 Submitted by webadmin on Wed, 2012-02-08 07:28 From Managed Care 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 … Read more

Username or e-mail address * Back to login page   Leave this field blank   STAY IN TOUCH! NEWSLETTERS AVAILABLE: P&T; and drug management daily news Editor’s letter (bimonthly) Managed Care table of contents (monthly) Paul LendnerPaul Lendner ist ein praktizierender Experte im Bereich Gesundheit, Medizin und Fitness. Er schreibt bereits seit über 5 Jahren … Read more

People flock to these services whether insurers cover them or not. When does it make economic and medical sense to offer them? Sherrie Dulworth, RN Just a few years ago, complementary and alternative medicine (CAM) was a hot topic in managed care and employer circles. In 1997, Oxford Health Plans pioneered a comprehensive CAM program … Read more

Insurers are playing ‘small ball’ and not showing leadership, says the former congressman. And some ‘spin-dry’ inpatient providers are doing more harm than good in combating the opioid epidemic. Meanwhile, Kennedy, who chronicled his own harrowing mental health and addiction struggles in a 2015 memoir, says he has been sober for more than six years. … Read more

Do you think you have too many employees? Some physicians let doubts on that question fester, sending signals to the staff that can be ruinous to morale. Here are some ways to face the issue squarely. Jeffrey J. Denning Contributing Editor There are good statistics on the subject of physician office staffing. The Medical Group … Read more

Many experts predict that there will be a dearth of primary care doctors, but others are not so worried In response to warnings of a significant physician shortage, allopathic medical schools are expanding enrollments by more than 20 percent, and osteopathic schools are growing even faster. However, a cap on graduate medical education funding and … Read more

What do the State Children’s Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act, and the Patients’ Bill of Rights have in common? State health-policy types point out that these and other federal initiatives came into existence only after states did the heavy lifting. Twenty-six states had children’s health insurance programs, 47 had … 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

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 do it?” “How can we conduct a satisfaction survey that won’t disrupt office work flow?” “How do we translate satisfaction findings into … Read more

Our neighbors to the north deliver care that is cheaper, but there are disputes concerning quality and growing unrest with irrational rationing. Resources are finite. Demand is infinite. The United States and Canada have built health care systems that attempt to reconcile the irreconcilable imbalance between supply and demand differently. Adjacent geographically, the two nations … Read more

Blue Cross Blue Shield of Massachusetts believes its newly inked provider pact with Caritas Christi Health Care — a community-based hospital network in New England with a network of 1,100 physicians that cares for about 60,000 members — will help bury the industry’s fee-for-service payment model. In a nutshell, the payment plan — dubbed an … Read more

Prompt and accurate payment by insurers is important to physicians, and the new 2007 PayerView Rankings provided by Athenahealth, a company that provides services to medical groups, attempts to show which insurers are the best and the worst at paying. Of national payers, Cigna, which ranked only fifth in 2006, is best this year. Last … Read more

A Quiz: Name That Health Care Model Submitted by Steven Peskin MD on Fri, 2012-01-06 17:16 What do these characteristics bring to mind? Flexible appointment scheduling Advanced electronic communication Care coordination Counseling and education Electronic prescribing Electronic health record with patient portal If you thought Level 3 Medical Home, you were correct. If you thought … Read more

Premera’s method of analyzing the potential benefits of Byetta shows how third-party modeling can pinpoint which members can benefit from easier access — and how plans can determine authentic cost savings John Carroll Contributing Editor John Watkins, RPh, the pharmacy manager in charge of formulary development at Premera Blue Cross, clearly recalls the first reaction … Read more

The belief that Medicare is a more efficient system than employee-sponsored health insurance comes under fire in a study that claims there are hidden costs in the government program. “One of the most common, and least challenged, assertions in the debate over U.S. health care policy is that Medicare administrative costs are about 2 percent … Read more

A CONVERSATION WITH WILLIAM F. JESSEE, M.D. The president of the Medical Group Management Association encourages changes that would bring physician practice and medical record-keeping in step with the times, and decries the lack of medical standards across plans. Group Management Association, which represents the interests of 185,000 physicians in more than 7,100 medical groups … Read more

It’s Managed Care 2, Lawyers 0, in the question of whether ERISA requires health plans to disclose physicians’ financial incentives. The U.S. Fifth Circuit Court of Appeals upheld a lower court ruling that dismissed a case against several HMOs. Health plans still face a number of class-action suits, however, over various types of incentives; one … Read more

By Susan A. Gibbs, J.D. Perhaps the most prevalent of “deal-killer” provisions today is the “hold-harmless” clause. The hold-harmless clause essentially says that the physician must indemnify the managed care organization and hold it harmless against liability. These provisions require the physician to reimburse the managed care organization for legal fees or liability settlements paid … Read more

Bundled payments, big data, and advances in personalized medicine will change the way primary care physicians and others practice David B. Nash, MD, MBA, envisions walking into his primary care practice and accessing an array of tools designed to help him provide the best, most cost-efficient care possible to engaged patient partners — and then … Read more

Approval decision expected in February 2017 The FDA has informed Clovis Oncology, Inc., that it is not planning to hold an advisory committee meeting to discuss the company’s new drug application (NDA) for rucaparib. The company is seeking approval of the drug for the treatment of advanced ovarian cancer in patients with BRCA-mutated tumors who … Read more

Almost everyone agrees that tobacco use is the single most preventable cause of death in the United States and a key factor in America’s $1 trillion annual bill for chronic care. Yet until recently, the major payers for health care have done nothing to bring the smoking rate down. That is changing, thanks in part … Read more

Employing those genetic markers, health providers might possibly conjure opioid therapy more straightforward to suppress the recurrence rate of deaths from these types of drugs. Over 17,500 Americans expired in 2015 from pharmaceutical opioid overdoses, and it is significantly more than simply the total of those who perished from this origin in 1999. Nonetheless, it’s … Read more

Type Title Name Story Are You Prepared for ICD-10? webadmin Story Healing Power of Color As Cheap as Coat of Paint webadmin Story Why Managed Care Is Getting A Bad Rap webadmin Story Health Care Resource Utilization and Costs Associated with Restless Legs Syndrome Among Managed Care Enrollees Treated With Dopamine Agonists webadmin Story Inter-Rater … Read more

Omalizumab, a novel therapy that targets specific steps in the inflammatory cascade of asthma, may benefit the hard-to-treat patient. Gailen D. Marshall Jr., MD, PhD University of Texas Health Science Center at Houston Medical School Full text in PDF ABSTRACT Purpose. To review the characteristics of difficult-to-treat asthma and describe patients who may benefit from therapy … Read more

Managed care executives call it reinsurance. Provider and physician groups usually call it stop-loss or provider excess. But the core idea is the same: buying some insurance protection against those ultra-expensive “shock” claims that can wreak years’ worth of financial havoc with just a few days of hospital charges. Until fairly recently, reinsurance was a … Read more

New hepatitis C medications fuel rising costs The Kaiser Family Foundation has examined trends in Medicare spending on prescription drugs, how Medicare coverage affects beneficiary access and costs, and what the public thinks about different options for keeping drug costs down. The foundation found that total and per capita Part D spending has increased rapidly … Read more

MANAGED CARE December 2010. ©MediMedia USA A committee at the Institute of Medicine has called for better use of registered nurses, but physicians continue to try to keep them subordinate John Carroll The simmering controversy over whether advanced-practice nurses should be deemed full-fledged primary care providers seems to be coming to a boil. There are many physician-oriented … Read more

NATIONAL POLICY Gore, Bush, McCain, and Bradley differ in some of the details. None of them really stands out from the crowd. When it comes to managed care issues and the four leading candidates for president, the differences are in the details. Although there are some variations in health care policy between Vice President Al … Read more

Physicians increasingly ignore clinical guidelines for treating back pain, causing skyrocketing costs with approaches that put patients at risk from unnecessary surgery, overuse of narcotics, and other problems, according to a study in JAMA Internal Medicine. “Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and … Read more

MANAGED CARE November 1999. ©1999 MediMedia USA John La Puma, M.D. It’s always been downstate versus Chicago. Rural versus urban. Simple versus sophisticated. Agriculture versus industry. Shawnee National Forest versus the County of Cook. But in a harbinger of things to come, Illinois is beginning to speak with one voice. On the last day of September, the … Read more

After years of private experience and training, I have found that entrepreneurs share virtually identical qualities which make them more successful. Luckily, each one these qualities might be heard. It’s your choice to carefully test your own strengths and devote yourself to learning . The first characteristic that most successful marketers must have is selfdiscipline. … Read more

Managed care can survive and may even thrive, experts say. But that will be in a world where public payers loom larger, provider prices are pushed down, the wellsprings of illness are addressed, and consumers aren’t quite so frustrated and angry. M​edicare Advantage for all? If a four-word forecast of managed care’s future had to … Read more

We have all heard those ominous numbers forecasting that half of all drug costs will be from specialty products in the near future. As is evident from the graph below, the future is not far off because, according to Avalere, adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) were among the 10 drugs with highest revenue … Read more

Successful Treatment of Insomnia Starts With Formulary Design Many insurers may not consider insomnia a serious health problem, but it costs employers a bundle in lowered productivity Inadequate identification and treatment of insomnia has serious medical and public health implications, resulting in impaired productivity, diminished quality of life, and potentially life-threatening comorbidities. According to several … Read more

Once guidelines are embedded in the work flow, it will be much easier to apply them than it is when physicians must essentially take them off the shelf and look them up. When he was 10, Jim Schibanoff watched a physician save his father’s life by correctly diagnosing and treating a ruptured appendix. That act … Read more

There was little difference between the options in terms of the frequency and cost of return visits. Patients receiving one-stage reconstructions returned slightly less often for breast-related services during the first 18 months after reconstruction, but the difference was not statistically significant. Also available in PDF Abstract Objective: Growing acceptance of nipple-sparing mastectomy and rising rates … Read more

The young oncologist’s Complaint of cancer screening and Surrogate end points has awakened. He says he simply wants drug-makers others to fulfill high standards of signs. Thus, among those suggested advantages of Social networking is that it hastens our vulnerability to how other men and women think, and thus can make us open-minded. Whether that … Read more

By Mike Folio, J.D. I know what you’re doing,” said the management services organization administrator, stopping me in mid-sentence. “You’re just trying to generate fees. I don’t like attorneys padding their billable hours.” I was negotiating an MSO contract for a family practice physician, trying to explain the potential patient privacy problems of the MSO … Read more

Overusing erythropoiesis-stimulating agents to collect rebates can be really bad for the patient. Ripping off taxpayers and private payers is another concern. The month of May was tough on the manufacturers of anti-anemia drugs. Reports emerged that some oncologists and nephrologists were receiving rebates of millions of dollars if they purchased bulk supplies of darbepoetin … Read more

Medical directors are worried about biologics, expecting that the success of these state-of-the-art medications will be the top cause of increased costs in 2006, according to a study by the consulting company MedPanel. The survey of health plan medical directors, representing about 30 million lives, indicates that health plans are increasingly turning to PBMs to … Read more

Reinventing Hospice Medicare considers going beyond palliative care, and Aetna finds that allowing curative treatment and loosening admission criteria reduce costs and improve quality of life Susan Worley Patient Liquidity at Time of Service Big New Problem for Providers, Insurers Insured patients are liable for ever greater out-of-pocket payments, and providers will have to evaluate … Read more

Incentive compensation systems are primarily utilized to boost productivity and efficiency of their work force, but businesses may also utilize these to increase employee recruitment, participation, retention and company branding. Incentive compensation programs result from the notion that rewards induce behaviour. Applied into the organization setting, incentive payment programs empower businesses to produce targeted results … Read more

BY FRANK DIAMOND Senior Editor Nothing sets off shock waves within a hospital more than a pending visit from surveyors with the Joint Commission on Accreditation for Healthcare Organizations. Staff meetings are held, action plans are developed and “rehearsals” are scheduled in which administrators — pretending to be Joint Commission surveyors — “interview” employees about … Read more

The fact that we waste hundreds of billions a year is all the more infuriating because we have the ability right now to stop the hemorrhaging Joseph Burns Contributing Editor Call it the $750 billion question. That’s the estimate for how much the U.S. health system wastes each year, according to the Institute of Medicine. … Read more

The trend lines and bar charts are marching up. Investors are investing, insurers are extending coverage, health care systems are getting on board. But there are some skunks at the telehealth garden party: research suggesting quality and utilization problems and lingering uncertainty about reimbursement. Telehealth is one of the buzziest areas of American health care, … 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

John A. Marcille Is “crisis” too strong a word for the increasing concern by businesses over the current inflation in health care costs? I wonder. Contributing editor John Carroll, in his cover story on this topic, cites the continuing cries of pain from the business community. The pain is real. Even though the dollar has declined relative … Read more

When diet is not enough, a well known metabolic disorder can now be managed better through medication Phenylketonuria (PKU) is a disease that most of the readers of this column have probably heard about as a result of having their own children screened for the condition at birth. It is an inherited disease that follows … Read more

BY TIMOTHY KELLEY She was quite tactful about it, all things considered. Having prepared our cover article on interpreting recent surveys about managed care, health care opinion specialist Karen Donelan, Sc.D., of the Harvard School of Public Health had just seen for the first time the “fax-back” survey we’re asking Managed Care’s readers to complete. “Could … Read more

Two authors independently assessed study quality before extraction of data and writers’ interpretations. The data were compared and compared, then piled in to outline of findings announcements, subjects and also a lineup of debate synthesis. Each of SoFs were Confidence from the Evidence from Reports of research analyzed. 17 newspapers were contained, involving 483 caregivers … Read more

The consolidation of member plans in the Blue Cross and Blue Shield Association has hit yet another snag. The Kansas Supreme Court on Aug. 6 upheld an order blocking the $190 million sale of the not-for-profit Blue Cross and Blue Shield of Kansas to Anthem, a for-profit operation. In making the decision, the court cites … Read more

The physician shortage isn’t going away but the gap between supply and demand may be smaller than previously predicted. The Association of American Medical Colleges has revised projections it made in 2010. Instead of a shortage of 130,600 doctors by 2025, an association report published this year puts the shortage between 46,100 and 90,400. Projected … Read more

The 15 percent discount is the same price gap set when Zarxio was launched in Europe in 2009, although the discount in Europe has since widened to an average of around 20 to 30 percent. Insurers hope biosimilars will eventually cost the public 40 percent to 50 percent less than the original brands. Neupogen is … Read more

Focused ultrasound destroys brain tissue The FDA has approved the first focused ultrasound device to treat essential tremor in patients who have not responded to medication. ExAblate Neuro (InSightec) uses magnetic resonance (MR) images taken during the procedure to deliver focused ultrasound to destroy brain tissue in a tiny area thought to be responsible for … Read more

Employers shopping for health care in 2009 will find that premiums will increase on average 10.6 percent in the next year, a bit less than in 2008, according to a new report by Aon Consulting. The company surveyed more than 70 health insurers who collectively cover more than 100 million people. They found that premiums … Read more

Mobile Health: Real Game-Changer Mobile apps, approved by the FDA or not, are already profoundly affecting the management of care Michael Levin-Epstein A Conversation With Delos M. ‘Toby’ Cosgrove, MD: Provider-Side Economics The head of the Cleveland Clinic on consolidating, reducing FTEs, and keeping physicians engaged AHRQ’s Free Research Can Help Plans Anticipate Coverage Issues … Read more

Discussions » Health Plan 2009 » J.D. KLEINKE: ‘A Final Underwriting Death Spiral’ Show: Today’s Messages  :: Show Polls :: Message Navigator J.D. KLEINKE: ‘A Final Underwriting Death Spiral’ Fri, 09 January 2004 11:11  admin Messages: 8 Registered: January 2004 Junior Member J.D. Kleinke is a medical economist and consultant based in Portland, Ore. His … Read more

The FDA has given a fast track designation for CTX001 for its Treatment of transfusion-dependent beta-thalassemia. TDT is a serious, innovative type of Betathalassemia characterized By acute anemia, transfusion addiction, inevitable iron overload, acute comorbidities, and also a shorter life span as well as the overall populace. Patients who have TDT desire life-long supportive attention … Read more

They’ve been burned here in the past, but physicians ­ and the HMOs that they contract with ­ may have learned some lessons. By JOHN CARROLL Contributing Editor When David Calabrese took over two years ago as director of managed care pharmacy for Provider Service Network, a Boston management services organization, he was stepping into … Read more

A consortium of manufacturers has received FDA approval to launch a generic version of the huge-selling proton-pump inhibitor Prilosec (omeprazole). The launch is expected by the end of the year. Although odds are that this could be the most significant commercial introduction of a generic product in history, cost savings are expected to be relatively … Read more

The 6,600-member Medical Society of Virginia has been searching for a managed care organization to work with for about a year. The society never considered a partnership with United HealthCare Corp. of Minneapolis. But in a strange turn of events, the two are forming a joint venture to develop a statewide managed care plan in … Read more

What health plans will spend on traditional drugs is falling, caused by the wave of patent expirations for blockbuster drugs. Express Scripts, a pharmacy benefit manager, reports that spending for traditional drugs will decline through at least 2015. In its 2013 Drug Trend Report, the company expects spending to be –1 percent in 2013, –1.7 … Read more

While HMOs seemed to be losing enrollees to PPOs, the ratio of enrollees in for-profit and not-for-profit HMOs stabilized in the late 1990s, according to data collected by the Centers for Medicare and Medicaid Services. The not-for-profit proportion “declined through the mid-1990s, but has been relatively steady at about 36 percent to 37 percent over … Read more

The sitcom created by Chris Rock, Everybody Hates Chris(link is external), which ran from 2005 until 2009, conjured laughs out of the everyday. One bit I particularly relish is when the narrator (the persona of Rock as a teenager) says that his father was like Rain Man when it came to knowing what everything costs. “That’s … Read more

One in six Americans has no health insurance, but that rate is even higher in the Southwest. According to Health Insurance Coverage 1998, a Census Bureau report released in October, nearly 1 in 4 Texans and Arizonans and about 1 in 5 Californians, Nevadans, and New Mexicans is uninsured. Why does the Southwest — tourist … Read more

Raking health plans over the coals can be a recreational and popular blood sport enjoyed by senators on both sides of the aisle in Washington. Sometimes it’s even warranted. But when critics alleged that insurers make excessive profits and pay excessive bonuses to their CEOs, they’d better have the facts — and they don’t. A … Read more

CONTRIBUTING VOICES Medication Nonadherence: $290 Billion Problem Research from the New England Healthcare Institute has the world rethinking what the next great advance in health care will look like. While many of us are only now beginning to hear the noise about medication nonadherence, health care leaders are already hot on the trail to finding … Read more

Even the USA has a bigger percentage of maternal deaths compared to least 40 additional nations, although it spends more money per capita for maternity care compared to any . The absence of an extensive, confidential strategy of ascertainment of maternal departure built to examine and record every maternal death has been subject U.S. women … Read more

Collins Was”held by the Trump government “,” NIH spokesperson Renate Myles said in A19 January announcement. It’s not yet determined whether Trump will officially reappoint Collins, or if Collins will always be in his job just until Trump appoints a permanent manager. Myles Led further questions regarding Collins’s status into the Trump transition crew. “We … Read more

Acorda Therapeutics has announced that it will discontinue the development of Plumiaz (diazepam) nasal spray, an investigational therapy being studied for the treatment of seizure clusters in patients with epilepsy. Data from the ongoing clinical trials failed to demonstrate the product’s bioequivalence to Diastat AcuDial (diazepam) rectal gel (Valeant), which was needed to refile a … Read more

Standardization, a central database, and quick reporting are thought to improve safety A recent survey of 28 organizations reveals widespread concern about many aspects of the REMS (risk evaluation and mitigation strategies) program, which is the FDA’s primary tool for proactively addressing specific safety concerns about new and existing medications. (See “Scope of REMS Programs” … Read more

To supplement our coverage of the business of medicine, Managed Care publishes scientific peer-reviewed studies relating to the cost and effectiveness of programs, products, and procedures in health care financing and delivery. When Managed Care published its inaugural issue in 1992, we made a commitment to our readers to help them understand what was then … Read more

Color chart Also available in PDF Medical groups give more ground to insurers Discounts that physician group practices give managed care companies are growing ever-deeper. A survey by the Medical Group Management Association found that the percentage of the full charge for a service billed by group practices, called the fee-for-service gross collection percentage, dipped … Read more

Ruling on queries from phone banks, working to end hospital errors, meeting with disgruntled physicians: Does any of this sound familiar? The first thing you notice about Ronald Brooks, M.D., is your second surprise of the day. Brooks, a network medical director for Aetna U.S. Healthcare, has agreed to let you follow him around so … Read more

Name Last modified Size Description Parent Directory – ../../archives/0004/0004.compmon.gif 01-Apr-2000 12:00 46K 0004.compmon.html 13-Jul-2007 12:20 1.9K ../../archives/0004/0004.compmon.pdf 01-Apr-2000 12:00 31K 0004.contents.html 13-Jul-2007 12:20 3.8K ../../archives/0004/0004.cover.jpg 01-Apr-2000 12:00 10K 0004.daimler.html 16-Jul-2007 08:25 12K 0004.editorsmemo.html 16-Jul-2007 08:25 2.8K 0004.ethics.html 16-Jul-2007 08:25 7.5K 0004.finger.html 16-Jul-2007 08:25 14K 0004.ipas.html 16-Jul-2007 08:25 24K 0004.legal.html 16-Jul-2007 08:25 6.5K 0004.news_amap.html 13-Jul-2007 12:20 … Read more

A growing number of health plans are adding these clinics in retail stores to their networks and are realizing savings Retail health clinics. All the major health plans are adding them to their networks. Busy families are demanding simpler ways to deal with routine health problems, and some of them are turning to the local … Read more

As a whole, the plan unceremoniously crashed and burned. But it still frames state and national debate about health policy, thus affecting the evolution of managed care. By Michael Levin-Epstein Contributing Editor When managed care executives are asked to “free associate” about the Clinton administration’s health care reform plan, two words invariably crop up: “Hillary” … Read more

“Financial toxicity” has become a common term used from the conversation of all cancer drugs, also it’s gaining traction from the literature supplied that the elevated price tag of newer types of treatments. Nevertheless, since a happening at the treatment and care of people who have cancer, even financial toxicity isn’t fully known, with the … Read more

FROM MANAGED CARE MAGAZINE WASHINGTON WATCH: Outpatient PPS Regulations Latest Source of Anti-HCFA Anger The Health Care Financing Administration continues to be one of the most besieged agencies in the federal government. For months, providers have excoriated HCFA, frustrated over regulations, paperwork, and payment schedules. Now, providers are attacking the agency’s rules for the prospective … Read more

Results Could Have Major Impact on Treatment Costs A new study by Mayo Clinic researchers could have a widespread impact on the treatment of patients with predominantly benign thyroid disease and newly treated hypothyroidism. Researchers looked at whether generic and brand-name levothyroxine therapy affected hospitalization for cardiovascular events in patients with a higher risk of … Read more

A subsidiary of Aetna U.S. Healthcare is the first HMO to face a malpractice lawsuit under a recently enacted Texas law. The suit against NYLCare of Texas was filed by the family of a 68-year-old Fort Worth man who committed suicide by drinking antifreeze hours after being discharged from a psychiatric hospital over his physician’s … Read more

The government wants to build an electronic system through which insurers, physicians, and hospitals can communicate. Snomed CT may solve a lot of problems. John Carroll Medical directors often complain that gathering health care data can be prohibitively expensive and severely hobbled by a conflicting set of competing electronic languages. But that may be about … Read more

Despite anecdotal reports to the contrary, the great majority — 87.6 percent — of physicians have contracts with managed care organizations. A new report from the Center for Studying Health Systems Change says that in fact, 70 percent of physicians had contracts with five or more managed care plans. How does this affect a physician’s … Read more

SUBSCRIBE TO E-NEWSLETTERS: P&T; and drug management daily news Editor’s letter (bimonthly) Managed Care table of contents (monthly)   2015 2016 2017 2010 2011 2012 2013 2014 2005 2006 2007 2008 2009 2000 2001 2002 2003 2004 1996 1997 1998 1999 1997 January 1997 February 1997 March 1997 April 1997 May 1997 June 1997 July … Read more

The Affordable Care Act is making strides in the young adult demographic, with five national insurers indicating that more than 600,000 young adults have obtained new insurance coverage since a provision in the ACA allowed them to stay on their parents’ insurance until age 26. A report from the Commonwealth Fund says that in 2010, … Read more

The American Cancer Society (ACS) has endorsed human papillomavirus (HPV) vaccination recommendations from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), the principal source of guidance on U.S. immunization policy. An updated guideline from the ACS supports the ACIP recommendation to vaccinate males as well as females at ages 11 … Read more

John Marcille There’s a lot about technology in this issue. A story examines how health plans are dealing with the genomics revolution. Read about some amazing patient-monitoring systems that promise a bright future for disease management. Then get a glimpse at how information technology might at last foster greater cooperation between health plans and provider networks. I say … Read more

Journalist David France’s How to Survive a Plague is a searing firsthand account of the early years of the HIV/AIDS epidemic in New York City. AIDS activists, most of them gay men, were fighting for their lives. Researchers, politicians, public health officials, and pharma were slow to respond—or resisted outright. The subtitle of your book includes … Read more

Formulary committees once were stocked with academics and administrators. Today, primary care physicians, specialists, and retail pharmacists play a bigger role, and tomorrow’s membership will be even more diverse. MargaretAnn Cross Contributing Editor Decisions about what medications make it onto a health plan or hospital formulary — and the level at which they are covered … Read more

Skeptics wonder if sticking sick people with high out-of-pocket costs simply encourages them to avoid care John Carroll For large self-insured employers and the managed care companies that cater to them, wellness programs have become one of the most popular feel-good strategies in the battle to contain costs. However, the controversy over health care reform … Read more

By David L. Bloom In ancient Greece, the Father of Medicine himself observed that patients hampered their own healing by straying from treatments prescribed for them. Hippocrates cautioned his students to be wary of noncompliance. Twenty-four centuries later, the problem persists and is a significant deficiency in the managed care system. As physicians and plans … Read more

Physicians should learn how to talk to patients about money, according to a new study from Wake Forest University School of Medicine, especially as health insurers force people to base more treatment decisions on out-of-pocket costs. “Each year, doctors are finding more and more that patients are coming in carrying substantial deductibles and having to … Read more

Details may vary according to the characteristics of the providers, but there is a general framework Peter Wehrwein inShare Tweet Widget (link is external) Commercial payers can be a little reluctant to get into a lot of details about their accountable care organization (ACO) contracts, not wanting competitors to know too much. It’s also true … Read more

Small and medium-sized physician practices use just one-fifth of patient-centered medical homes’ processes. On the other hand, large practices and those owned by hospitals or HMOs use more medical home processes, like chronic disease registries or nurse care managers. Results were published in the August issue of Health Affairs.… This year’s new flu vaccine formulation … Read more

Another strategy relies on the observation that the degradation of intestinal metaplasia by means of an assortment of thermal and chemical techniques could come with regeneration of normal-appearing squamous epithelium, especially when the patients have been treated using proton pump inhibitors to maintain them achlorhydric. One of the countless endoscopic methods which can be designed … Read more

Poor financial performance associated with risk contracting between medical groups and insurers appears to be a thing of the past, according to “Capitation and Risk Contracting Survey” from ECG Management Consultants and the American Medical Group Association (AMGA). More than half of medical groups characterized their organizations’ financial performance in risk contracts over the past … Read more

If 1% of patients account for 21% of total health care spending, why is there so little proof of ROI from giving them appropriate care? Think about this for a minute: Jeffrey Brenner, MD, says we have no idea how to deliver better care at lower cost. Brenner is the highly regarded executive director of … Read more

Wrenching transformation in many forms is starting to be felt in many parts of the system. Here are ways to help resistant employees get on board. As the provisions of the Affordable Care Act continue to be implemented, dramatic changes are taking place with far-reaching implications for every area of health care. How, then, to … Read more

Organized oncology isn’t ready to give up on ASP+6 payment for Medicare Part B drugs. But experimentation with value-based pricing has some supporters. Change is hard and often unpopular. Change how people get paid, and they will get up in arms in a hurry. The reaction from oncology groups was overwhelmingly negative last month when … Read more

Affordable Care Act will have fewer, higher priced coverage options in 2017, as medical plans are still declare they’ll not sell their services and products in Texas. Insurance startup Oscar declared on Tuesday it might partly Take advantage of the Texas market, linking experienced health programs Aetna, UnitedHealthcare and Scott and White among of businesses … Read more

The Access to Life-Saving Medicine Act may be a first step to giving the FDA the legal authority to approve these drugs More than 25 years after Hatch-Waxman, no legal pathway for approval of generic biologic drugs exists. But if that redoubtable Democrat, Rep. Henry Waxman of California, has his way, an abbreviated approval process … Read more

BIOLOGICS IN DEVELOPMENT Viruses. You don’t want one — unless it’s one that attacks disease instead of promoting it. And yes, such a thing exists. In a trial involving patients with stage 3 or 4 melanoma, talimogene laherparepvec, or T-vec, Amgen’s cancer-fighting virus, came out swinging against granulocyte-macrophage colony-stimulating factor (GM-CSF). In an open-label study, … Read more

The California agency which governs physicians is exploring at least four doctors for devoting debateable healthcare exemptions to kids whose parents didn’t desire them . The Medical Board of California’s investigations are cooperating amid the world’s hardest measles epidemic in significantly more than the usual quarter century, as California law makers consider contentious laws to … Read more

Projected slow sales growth for big pharmaceutical companies is an opportunity for health insurance plans to save money. The compound annual growth rate for big pharma companies from 2010 to 2016 will be 0.7 percent thanks to “generic erosion,” says Datamonitor, a business information and analysis company. For pharmacy directors at health insurance plans, that … Read more

While about half of adults believe that there are fair and reliable ways to assess health care quality, only 19 percent think it would be justifiable for patients to pay more when treated by medical groups or hospitals that provide better care. The data result from an online survey of 2,123 U.S. adults that was … Read more

Ex-Prisoners In Need of Care There’s a gap in the proverbial health care safety net that’s big enough for a whale to swim through. People who are incarcerated, on probation, or on parole — what a recent study calls the “justice-involved population” — make up 22% of the 13 million newly eligible people. “The justice-involved … Read more

Although adherence rates among HIV/AIDS patients are as low as 50%, anything less than 100% is unacceptable because adherence to antiretroviral therapy (ART) is the primary factor that determines virologic suppression, disease progression, and even death. Therefore, evidence-based interventions to improve adherence have become a focus of formulary decision makers. One such intervention, known as … Read more

Train an in-house team to help make the transition smooth by determining who is affected, and how ICD-10 is coming, and some health plans are already planning how they will implement the system, training staff members, working with programmers, and looking at every aspect of their operation to make sure that they will be in … Read more

Cover Story For Health Insurers, Retail Space Available! Under health reform, consumers will be the new buyers in public and private exchanges, meaning care management programs will need a sharper focus on return on investment Joseph Burns Health Plans Won’t Sit Out While Docs, Hospitals Dance As providers scramble to form accountable care organizations, insurers … Read more

VIEKIRA XR can be really a once-daily, extended-release co-formulation of those ingredients in VIEKIRA PAK® and is accountable for the treatment of patients with chronic genotype 1 hepatitis C virus illness, for example individuals with compensated cirrhosis. VIEKIRA XR just isn’t for folks who have decompensated cirrhosis. VIEKIRA XR could be your first co-formulated three … Read more

Plans prod hospitals to do a better job of addressing problems that kill nearly 100,000 Americans a year Lola Butcher As the public reels from the new estimate that nearly 100,000 Americans are dying each year from infections associated with health care, some health plans are taking a lead in alleviating the problem in their … Read more

Were you aware that a pharmacy can possibly be refunded below the expense of the drugs they purchase? They do. And today it’s happening with increased frequency, and also the losses are unsustainable. As pharmacy benefit managers (PBMs), who put the reimbursements for some drugs that physicians purchase, increase their control within the drugstore marketplace, … Read more

Beware of the spillover effect regarding the endorsement of 12 measures for coordination of care last month by the National Quality Forum. The measures focus on areas such as medication reconciliation, proper use of the ED, and timely initiation of care. “The NQF has a special line to/relationship with Medicare, so anything recommended by NQF … Read more

As a way to apply medicine, your doctor needs to have graduated from medical history, fulfilled appropriate hospital conditions, and been approved by their nation’s official medical history. With board certificate, the exact same general eligibility conditions apply, however, the medic must meet other training conditions, complete an intensive application method, and pass standardized assessments. … Read more

Prevalence of obesity is growing in developing and developed states. As a result of accelerated increase in the weight and cost of obesity, globally, it appears reasonable to concentrate on the reduction of fractures whilst the chief objective of treatment. Even though, efficient herbal agents can be obtained for the treatment of gout, there still … Read more

Remember that pesky provider-sponsored organization insolvency problem? At press time, the federal PSO rulemaking panel was to meet for what members hope will be the last time to settle differences of opinion about solvency standards for federally approved Medicare-sponsored PSOs. The major stumbling block is how a PSO should define net worth when it applies … Read more

By Bob Carlson When it’s very good, you feel that you’re actually getting more value for your dollar. You may even find yourself smiling more and saying “hi” to people you don’t know. I’m talking about customer service. Granted, we probably think first of a retail setting when we hear that phrase. But for managed … Read more

Insulin-producing cells from the pancreas. Blood sugar that’s too much or too low could be lifethreatening, and patients must monitor their sugar several times every day. A long standing objective of type I diabetes research will be always to restore lost cells with fresh cells which release insulin to the blood as needed. Though researchers … Read more

Krishna Rutvij Patel, PharmD Of the 41 new molecular entities approved by the FDA last year, 17 (41%) were orphan drugs. There’s every indication that the trend will continue. That’s good news not only for the pharmaceutical companies but also for formulary decision makers at health insurers and PBMs. 2014 Orphan Drug Approvals Beleodaq (belinostat) … Read more

The Waiting Game: Managed Care and Dentistry  26A Combined managed health and dental coverage could save expenses for employers and improve care. But neither employers nor traditional HMOs have shown much interest in such packaged plans Will State Legislators Keep Playing Doctor?  28 Health care reform isn’t dead; it just comes in 50 different flavors now as … Read more

October 6, 2017 Cobas Zika test is made by Roche Molecular Systems The FDA has approved the first Zika virus detection test for use in screening the nation’s blood supply. The cobas Zika test (Roche Molecular Systems, Inc.) is a qualitative nucleic acid test for the detection of Zika virus RNA in individual plasma specimens … Read more

MANAGED CARE December 2008. ©MediMedia USA Health plans continue to push patients towards off-label use of pain relievers and alternative treatments for symptom pain Martin Sipkoff About 10 million people suffer from fibromyalgia, a painful, persistent, and incurable disease that for too many years many physicians believed was entirely psychological. “There has always been a lot of … Read more

All the state-of-the-art health care literacy tools go for naught when faced with such ignorance   At a time when people make decisions about health care based on input from friends, family, physicians, the Internet, and a myriad of other sources, you can count Charlie Baker as a believer in the positive influence of a … Read more

Analytical studies, rarely used to evaluate biotechnology products, will need greater attention Tom Reinke The United States has yet to approve a single biosimilar. The FDA has had several meetings with biotechnology companies to discuss their applications for biosimilars as investigational new drugs (INDs), but as of September it had not received one application. In … Read more

Like the seasons, fiscal cycles are inexorable. No sooner had feuding Republicans and Democrats more or less decided to cool it on Medicare/Medicaid reform until after the election than the president sent the 1997 budget to the Hill–where it presumably will be tossed on top of its FY 1996 predecessor, which has yet to pass. … Read more

Even Though Having a Work-day Filled up with”a Lot of Regulations and Rules” and Hours allocated to trial, almost 8 10 U.S. medical doctors would select drug again being a livelihood, as stated by the consequences of this 20 17 Medscape Physician reparation Report. Medscape’s yearly investigation of compensation affects livelihood factors and gratification discovers … Read more

F​irst the good news: For employers and other health care payers, the medical cost trend this year will be, as it has been for the past several years, relatively stable. But now for that other, less desirable variety of news: The medical cost trend continues to grow at 6%, which is faster than the overall … Read more

A study of four Ordinary medical conditions suggests Associations Which Used intensive care units frequently were more prone to carry out invasive procedures and also have high costs while still showing no improvement in mortality, based on articles published on the web by JAMA Internal Medicine. The possible clinical consequences of Over-using ICU care, together … Read more

THE CONTRARIANS “We don’t know for certain whether there’s cost shifting going on, but it’s unlikely that people are turning around their health status so quickly” and savings have to come from somewhere, says Jill Horwitz, JD, PhD. Workplace wellness programs are increasingly popular with employers and vendors. Jill Horwitz, JD, PhD, has good reason … Read more

The adage “all politics is local” may, in the end, become the motto that sinks ERISA. HMO executives should assume protection will evaporate. By Allen Briskin and Gerry Hinkley In the coming months, a House-Senate committee will debate whether the next Patients Bill of Rights should give health plan members the right to sue their … Read more

This analysis could be the first ever to investigate soccer-related traumas and compute damage levels predicated on football involvement data one of kiddies in the federal point. The rising variety and speed of esophageal soccer-related harms, notably soccer-related concussions/closed brain accidents, highlight the demand for improved attempts to avoid such harms. A believed 2995765 kiddies … Read more

Novo Nordisk has announced the submission to the FDA of a biologics license application for the approval of nonacog beta pegol, a long-acting glycopegylated recombinant factor IX developed for patients with hemophilia B. The filing of nonacog beta pegol was based on positive results from the paradigm clinical trial program, which involved 115 patients with … Read more

The comparison found that maintenance therapy with fluticasone propionate-salmeterol combination was associated with a 14% reduction in risk of severe exacerbation, less health care utilization, and 25% lower COPD-related medical costs Anand A. Dalal, PhD U.S. Health Outcomes, GlaxoSmithKline, Research Triangle Park, N.C. Sean D. Candrilli, PhD RTI Health Solutions, Research Triangle Park, N.C. Keith … Read more

Year:  2011  |  2010  |  2009  |  2008  |  2007  |  2006  |  2005  |  2004  |  2003  |  2002  | 2008 January Cover Story Leading With Its Heart Program Plans Look Askance at Me-Too Medications Lax Coding by Physicians Hurts Medicare Advantage Plans Now Is the Time for Pharmacy Performance Incentives The Managed Care Forecast Peer-Reviewed Optimizing the Use of 17P In Pregnant Managed … Read more

It’s the growing season to roll your sleeves up, gather your records, and decide on a medical insurance coverage for 2020. For individuals searching to their very own plans, HealthCare.gov and one other country exchanges are available for registration at the time of November 1. Despite the rhetoric concerning the implosion of this Affordable Care … Read more

QUALITY IMPROVEMENT Yes, health care is a business, but altruistic plans would like to cooperate with others. The Leapfrog Group has set up a simple mechanism to do this. Jerry Salkowe, MD, vice president for quality improvement at MVP Health Care, spent part of a recent weekend entering information about the insurer’s quality incentive program … Read more

Health Plans Strain To Contain Rapidly Rising Cost of Imaging PET, CT, MRI — these and other imaging technologies are valuable but costly. Aetna, Cigna, and a few other plans lead in clamping down on unnecessary use. Maureen Glabman Breast Cancer Screening: Some Plans Do Better Than Others Some of the nation’s best health plans … Read more

The end point of reform may be physicians and patients gaining some power at payors’ expense. But for patients, a place at the table requires greater self-responsibility. THE FACULTY Philip R. Boulter, M.D., Senior Vice President and Chief Medical Officer, Tufts Health Plan John K. Gorman, President, Managed Care Compliance Solutions William F. Jessee, M.D., President and CEO, … Read more

July was a good month for Florida Medicaid Director Bob Sharpe. Pharmaceutical makers were cooperating with Florida’s new Medicaid formulary-and-rebate program, and Pfizer’s two-year, $33 million dollar initiative to improve the health status of Florida Medicaid enrollees was off to a flying start. Then on Aug. 7, Pharmaceutical Research and Manufacturers of America (PhRMA) filed … Read more

The resurgence of what was once primarily known as the insurer of last resort has been breathtaking. Can it be sustained? Even better, replicated? Frank Diamond Senior Editor Whoever said that you can’t argue with success knew very little about progress, and even less about human nature. Officials at Blue Cross and Blue Shield Association … Read more

John A. Marcille Some experts have long suggested that we should be able to buy health insurance the same way we buy car insurance. This maxim touches on the power of free markets and free will to transform a system. The mindset is one of knocking down barriers, in other words. However, one of the … Read more

A Washington Health Alliance report quantifies how pervasive low-value care is. ‘Drop the pre-op’ is the group’s first step toward eliminating it. Waste in health care is not new, but attention to it is rapidly gaining momentum. The Institute of Medicine provided the wake-up call in its 2012 report, estimating that about 30% of health … Read more

High-quality care is only part of the secret to scoring well on HEDIS. Understanding how to ‘do’ HEDIS is equally important. The business of HEDIS help is thriving. It wasn’t long ago–just two or three years –that the National Committee for Quality Assurance’s Health Plan Employer Data and Information Set had yet to achieve the … Read more

Health care costs continue to rise, but at a slower rate, reports Standard & Poor’s Healthcare Economic Composite Index. From March 2010 to March 2011 health care costs covered by commercial insurance rose by 7.6 percent. In comparison, Medicare claims costs rose at an annual rate of 2.8 percent. It’s the lowest annual rate of … Read more

Most insurers are wary about any data that comes from outside their plan and whether RWE can take root in non-integrated plans is an open question.   Real-world evidence (RWE) is the hot topic this year, a way to evaluate treatments—and make changes on the fly, if necessary—under a new president who thinks the FDA … Read more

Three tiers or four tiers are the drug benefit designs of choice among employers looking to rein in costs, according to findings presented in the Pharmacy Benefit Management Institute’s Pharmacy Benefit Cost and Plan Design Report. From 2007 to 2008, the percentage of employers who implemented a three-tier plan design with copayments rose from 45.3 … Read more

Healthy Blue Living in Michigan lets employers and members reap the benefits of lifestyle improvement Frank Diamond When Blue Care Network, the affiliated HMO of Blue Cross Blue Shield of Michigan, launched its wellness program five years ago, company officials were momentarily surprised by how quickly the effort grew, says Marc Keshishian, MD, Blue Care … Read more

Demonstrating the Value of Pharmaceuticals Across the Healthcare Continuum At the 16th Annual Managed Healthcare Symposium, some of the most knowledgeable health care experts in the United States were invited to lecture, debate, and explore medical innovation and the role of pharmaceuticals in the delivery of high-quality care. This supplement is derived from those discussions, … Read more

Profits should increase over the next two years for plans that stay the course, but politics and rising premiums may affect long-term results Profits should increase over the next two years for plans that stay the course, but politics and rising premiums may affect long-term results A congressional report estimates profits for the 12 largest … Read more

The dissociation rate constant of bimolecular complexes between macromolecules can be quantified by way of competition experiments and also is usually likely to follow along with first-order kinetics.When measuring k constants by contest for three complexes of both high-affinity recombinant antibody fragments with the cognate antigen and also for a single calmodulin/peptide complex, a sudden … Read more

Health insurers change their formularies to increase medical effectiveness and save money, and a new study from Case Western Reserve University has determined the effect these changes might have on patient care with respect to the prevalence of difficulty in filling a prescription and resultant problems. Questionnaires were mailed to 1,200 patients who had visited … Read more

Wharton’s Mark Pauly on health insurer mergers: worry not vs. worst of both worlds We have a story in the works here at Managed Care on the mega–health insurers that may soon be roaming the land. Yes, the deals may yet run into antitrust problems, but the way things stand now there will be three super-sized national … Read more

THE CONTRARIANS Publications that cover health care — this one included — are filled with stories about how physicians, hospitals, and insurers are working together to deliver better care at lower cost. Experts at conferences present slides showing how providers are driving down costs while improving quality. But there’s just one trouble, insists Jeffrey Brenner, … Read more

Several nations have expanded Medicaid eligibility for adults at the last ten years, and also the Affordable Care Act allows states to expand Medicaid radically in 2014. We analyzed if Medicaid expansions were correlated with changes in mortality and Different health measures The main outcome was all-cause county-level mortality one of 68,012 year- and – … Read more

The size of the essential benefits package may determine whether insurers can operate in the highly regulated exchange market. Expect strong lobbying from health care interest groups. Senior Contributing Editor Quick: Which aspect of health care reform is likely to have the biggest impact? The individual mandate? The health insurance exchanges? No-cost preventive services? The … Read more

As the medical home concept grows, many in health care will have to define new roles Add diverse experience as a clinician, health plan executive, and consultant to his current role as vice president and medical director at McKesson Corp. and David Nace, MD, is able to take a broad view of the value of … Read more

Studies suggest that the benefits of the medications for mild-to-moderate patients are minimal or nonexistent By Martin Sipkoff Most health plans and pharmacy benefit management companies pay for antidepressants, and many maintain depression management programs, so they have a vested financial interest in the efficacy of treating depression through medication and disease management. At least … Read more

The outcomes have been promising for some 20,000 elderly people and the insurer wants to replicate the effort in other lines of business Frank Diamond Managing Editor Outcomes for about 20,000 beneficiaries in Aetna’s Medicare Advantage offering underscore that health reform’s emphasis on accountable care organizations (ACOs) could pay off in the long run — … Read more

Substantial Improvements in our Comprehension of RA and its Own Management have Been manufactured in the last ten years, leading to earlier intervention together with biologic DMARDs, specially in patients with signs of competitive, erosive illness. Here, one biologic therapy, ” the t cell co-stimulation modulator abatacept, is discussed, researching clinical signs released so far … Read more

Just because you hear a whistle from two miles down the track doesn’t mean it’s time to hoist your heavy suitcase. American health care has been waiting a while for “value-based payment” to pull into the station. But don’t look for it to fully arrive in 2016. Propelled by the ACA’s ACOs and new Medicare … Read more

The Internet has turbo-empowered one of humanity’s noblest activities: Browsing. Webster (great name for a dot.com company) says “to browse” is “to eat or nibble off, as the tender branches of trees, shrubs, etc.” Browsing the web produces more information with less effort than any other source, at any time in history. It can also … Read more

There’s a demographic shift going on in the physician community, as well as in the country, according to a study by the American Medical Group Association. Doctors who are most likely to retire are men; their replacements are most likely to be women, according to the 2012 Physician Retention Survey. “This dynamic is clearly illustrated … Read more

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 agency’s latest move toward a post–fee-for-service world. The distribution of multiple chronic conditions People with multiple chronic conditions are a challenge … Read more

MANAGED CARE November 2005. ©MediMedia USA Good news for employers can be found in a study by Hewitt Associates that reports that health insurance costs increased by 9.2 percent this year. That’s the first single-digit increase since 2000. The report contained not-so-good news for employees. Their contributions to health care premiums increased 65 percent, from $877 per … Read more

He started blogging to get information out to physicians; now he believes that patients too will benefit greatly from e-mail, blogs, tweets, and the like A technology-savvy physician says YouTube and Twitter have the potential to improve patient-physician relationships — and to sharpen health care’s focus on wellness and prevention. When Ted Eytan, MD, began … Read more

The unprecedented growth of accessibility to healthcare internationally Within the past ten years ranging From countless thousands of men and women in non – and – high-income nations getting access via government programs and rising incomes into the decrease in the uninsured populations inside the usa — has prompted an increase in the attention of … Read more

Washington Watch Managed care and other health care organizations still are trying to figure out the probable effect of a U.S. Supreme Court decision that lays new ground rules for determining whether physicians and nurses who are employed at health care facilities are entitled to organize. In National Labor Relations Board v. Kentucky River Community … Read more

If there’s any doubt whether capitation has left a bit of a sour taste in the mouths of physicians and hospitals, a survey issued earlier this year would seem to confirm it. Physician-group involvement in capitation is down by one fifth over a two-year period, while 2 of every 5 hospitals have moved away from … Read more

The adage “all politics is local” may, in the end, become the motto that sinks ERISA. HMO executives should assume protection will evaporate. In the coming months, a House-Senate committee will debate whether the next Patients Bill of Rights should give health plan members the right to sue their HMOs and other managed care organizations. … Read more

The National government has Called six Part D Patrons Which are Engaging in its Improved Medication Treatment Management Model, that is defined to start next yr. The Improved Medication Treatment Control Model, that CMS surfaced last autumn , Allows standalone Component D prescription drug plans in select areas to commemorate the normal MTM version and … Read more

A CONVERSATION WITH CHARLES B. INLANDER The colorful president of the People’s Medical Society foresees fewer hospitals, more DM, “teledocs,” and an end to legislation by body part. Charles B. Inlander has been president of the People’s Medical Society since the group’s founding in 1983. The idea for the organization came from Robert Rodale, second-generation … Read more

The Food and Medication Organization and the Government Exchange Commission have a long history of working cooperatively to secure American buyers. We have officially worked together since 1954 to help the significant missions of both FDA and FTC. Quite a bit of our cooperative work centers around guaranteeing that publicizing and other limited time interchanges … Read more

In 13 years, use of paper-only patient health records fell from 69% to 1% Technologies that improve medication use have been adopted by nearly 100% of hospitals across the United States, according to a survey by the American Society of Health-System Pharmacists (ASHP). Implementation of technologies such as electronic health records (EHRs), computerized prescriber order-entry … Read more

John Carroll Contributing Editor As rising costs drive CEOs’ collective blood pressure off the charts, a group of experts considers whether managed care has reached another watershed — and whether the industry can reinvent itself yet again. MANAGED CARE September 2004. ©MediMedia USA As rising costs drive CEOs’ collective blood pressure off the charts, a group of … Read more

Not surprisingly, the House of Representatives’ 275-161 vote affirming the Norwood-Dingell health care reform bill prompted wailing and gnashing of teeth from the insurance industry. A Health Insurance Association of America study tallied 408 new mandates in the bill — more than double that proposed in Norwood’s 1998 legislation, PARCA. The American Association of Health … Read more

Using “joy” and “primary care physician” in the same sentence can be downright provocative these days, as the authors of a study that does just that point out. “We set out in search of joy. What we found were pockets of professional satisfaction.” Specifically, the authors — who include Thomas Bodenheimer, MD, a member of … Read more

Mostly it is self-insured employers that are offering the option, but health plans may well want to join in Surgery is scary, and no matter what the surgeon’s qualifications or bedside manner, most patients worry in the days preceding it. The ride to the hospital seems all too brief. However, an increasing number of patients … Read more

To contrast, in commercially-insured Individuals 240 yrs of age, the probability of chronic obstructive pulmonary disease exacerbations and COPD-related healthcare usage and costs from patients initiating care treatment with fluticasone propionate/salmeterol xinafoate 250 microg/50 microg with people in patients beginning treatment with tiotropium bromide. The Risk of COPD exacerbation, COPD-related healthcare usage, also COPD-related costs … Read more

Even While physicians have grumbled over Time how managed Maintenance and The corporate impact on medication has eaten in their incomes, and they still held a number of the very stable work in the country and may rely in their wages to equaling a few of their best inflation levels in recent years. But, COVID-19 … Read more

PCMH projects around the country have begun to demonstrate that the new strategy can reduce costs and improve the quality of care that people receive Every week, about a thousand patients wend their way through the waiting room of Philip Ptacin’s family practice in Battle Creek, Mich. Until two years ago, he informally assigned high … Read more

The Massachusetts secretary of state is waging war on the state’s not-for-profit HMOs, which financed the bulk of a campaign to defeat a ballot proposal that would have required the legislature to create a universal-care system in the state. William Galvin blasted the plans for poormouthing and cutting benefits while spending millions to defeat the … 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

“Insignificantly intrusive medical procedure decreases torment, scarring and recuperation time after a medical procedure,” said Binita Ashar, M.D., head of the Division of Careful Gadgets in the FDA’s Middle for Gadgets and Radiological Wellbeing. “RASD innovation is a particular advancement in insignificantly intrusive medical procedure intended to upgrade the specialist’s entrance and perception inside limited … Read more

No less than measuring and evaluating outcomes in disease management programs is the goal of a program launched by the Disease Management Association of America. “This certainly stands among the disease management community’s most significant research efforts to date,” says Don Fetterolf, MD, chairman of the DMAA Quality and Research Committee. “Reaching consensus on a … Read more

When we parted last issue, memories of the November government shutdown were fresh. Official Washington eventually lurched to its feet again in the wake of a second shutdown-cum-blizzard that paralyzed the city for nearly a month. In a 30-day period ending in January, federal workers in Washington were at their desks a grand total of … Read more

The lesson from Medicare’s demonstration projects for disease management, according to the Congressional Budget Office, is that DM does not work. “In nearly every program involving disease management …, spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program, when the fees paid to the … Read more

Roger Bolus, Ph.D. Jennifer Pitts, Ph.D. Surveys say a lot about quality and are continuously conducted by HMOs and accrediting bodies. The authors suggest medical groups follow suit. MANAGED CARE April 1999. ©1999 Stezzi Communications Surveys say a lot about quality and are continuously conducted by HMOs and accrediting bodies. The authors suggest medical groups follow suit. … Read more

LEGISLATION & REGULATION One of the purposes of health care reform was to create more competition, and the recent spate of acquisitions works against that. Four of the big five commercial health plans have lined up suitors for merger. Aetna and Humana have paired up in a $37 billion cash-and-stock deal, and Anthem wants to … Read more

Letter To The Editor MSSP risk free, not saving money? That’s ‘insane’ Reliance ACO is a Track 1 that started in 2014. We have saved CMS over $32 million and have received money back in two of the four years. We also have a Next Gen product that is a risk program. I want to … Read more

The very first individual to be identified using Ebola Outside Africa throughout the newest outbreak has been shipped home with a length of antibiotics to get fourteen weeks later seeking health attention at a Dallas hospital the other day, a hospital official said. The Patient, considered to be man, has been admitted into an isolation … Read more

Sidebar to “Where Will Health Plans Find The Next Generation of Savings?” Plan: Humana Strategy: Humana rewires its systems, in the process, rebuilding relationships with patients and providers Progress: Launches in Memphis on Jan. 1 Humana Chairman David Jones told a group in June that he was reinventing the company he cofounded — again. “Sometimes,” he said, “you need … Read more

Clinician executives who want to relieve stressed-out physicians, and perhaps help stave off doctors leaving the profession, can start by encouraging the recruitment of nurses, physician assistants, nurse practitioners and other ancillary caregivers, according to a survey by Cejka Search and Physician Wellness Services (PWS), a company that helps doctors manage stress. “Physicians surveyed indicated … Read more

Washington Watch HMOs may delay compliance with HIPAA electronic transactions and code reporting requirements for one year under legislation passed by Congress late last year. However, the new law doesn’t affect information privacy requirements slated to take effect in 2003. If health plans want to forge ahead with compliance, federal regulators aren’t going to object … Read more

Introduction Editorial Advisory Board Instructions for Authors Papers already published: www.managedcaremag.com/research To supplement our coverage of the business of medicine, Managed Care publishes scientific peer-reviewed studies relating to the cost and effectiveness of programs, products, and procedures in health care financing and delivery. When Managed Care published its inaugural issue in 1992, we made a commitment to our readers to … Read more

Prostate But, evidence supporting the overall survival advantage from men experiencing PSA screening is contentious, resulting in some lack of consensus on tips. The Current article article offers an summary of the very significant studies on PSA screening involving the most recent upgrades of high trials. Furthermore, modern theories in ancient detection of PCa which … Read more

These high-achievers wrestle with competing interests as they operate both in the medical and business worlds After 13 years in neonatal intensive care, Marjorie Schulman, MD, became a clinician executive, working as a medical director. She left Aetna at the end of 2011. She loved it there, calling it an ethical company that has done … Read more

New website may aid appropriate treatment choices   The FDA, seeking to get critical updates on antibiotics and antifungal drugs to health care professionals more quickly, has created a website that will provide direct and timely access to information about when bacterial or fungal infections are likely to respond to a specific drug. The new … Read more

Even as the health insurance industry comes under increasing political fire (Medicare for All, anyone?), it continues to lure beneficiaries into Medicare Advantage, with 2019 looking to be the best year ever for the program. Of course, as has been noted, MA plans may have an unfair advantage over traditional Medicare. MA plans bid against … Read more

More people report that they have high blood pressure and are taking medications to combat it, according to the Centers for Disease Control & Prevention, but there are still far too many people who are untreated. “From 2005 to 2009, the prevalence of self-reported hypertension among U.S. adults increased from 25.8 percent to 28.3 percent,” … Read more

Download PDF Abstract Purpose: To analyze commercial payer differences in the average costs and readmission rates between inpatient open hysterectomies and three types of outpatient hysterectomies: laparoscopic, laparoscopic assisted, and vaginal. Design/Methodology: A retrospective claims data analysis was conducted using the 2012 and 2013 Truven Health Analytics MarketScan Commercial Claims and Encounter Database. The study … Read more

Payers should benefit as the rate of introduction of blockbuster products declines When the Provenge prostate cancer vaccine was approved earlier this year, the closely watched move was greeted with an outpouring of hope and enthusiasm. This marked the first time that immunotherapy was endorsed as a weapon in the fight against cancer. Patients rejoiced. … Read more

When magazines like this one recommend some action to physicians as “worth the time it takes,” do you sometimes wonder where the time is supposed to come from? This article may help. Time is the currency of managed care. Unfortunately, patients feel they need 30-minute office visits, while HMOs believe they only require 15. Doctors … Read more

Physician practice management companies are becoming more powerful — they’re the “next big thing” in the field of managed care. PPMs seem to make good partners for managed care companies, but might they also be treading on health plans’ turf? Peter Wehrwein Contributing Editor It sounds an awful lot like what HMOs are supposed to … Read more

With 9% of hospital charges attributable to pregnancy, delivery, and neonatal care, there is considerable opportunity for savings The idea of staying in a hotel room for several weeks instead of a hospital room appealed to a pregnant woman who needed bed rest because she was experiencing complications. And paying for the hotel reduced costs … Read more

INTRODUCTION AND WELCOME Old Saying Appropriate For Current Environment David Brennan, Senior Vice President, Commercialization and Portfolio Management, AstraZeneca Pharmaceuticals KEYNOTE Health Status, Health Maintenance, and Health Care in the 21st Century Louis Sullivan, M.D. , President, Morehouse School of Medicine; Secretary, U.S. Department of Health and Human Services, 1989­1993 PANEL DISCUSSION Health Care Reform: … Read more

Medicare pullouts for 2000 are mounting. Sentara plans to drop the Norfolk, Va., area’s only Medicare+Choice plan next year. Harvard Pilgrim will abandon western Massachusetts, and HIP will leave Tampa…. Contraception coverage is a big state-level issue. Georgia, Hawaii, and Vermont passed coverage mandates this year; 28 states and Puerto Rico are considering them…. The … Read more

Open a newspaper or magazine or turn on your television these days, and you’ll soon see a report that casts an HMO in a bad light. Here are 10 reasons for managed care’s current run of bad publicity. A headline decries kicking new mothers out of hospitals. A TV talk show bemoans gagging doctors. A … Read more

The 11 new measures — as is the case with those already in place — focus on problems that greatly affect their employees, and therefore overall costs. Some health plan executives will probably grouse about the expense of complying with the newest HEDIS guidelines, since the draft of HEDIS 2004 includes 11 new measures (see … Read more

Two California HMOs are hanging their physician group ratings out on the Internet for the world, literally, to see. Health Net’s report cards Health Net’s second annual member satisfaction report card separates groups by region. Performance is relative to other physician groups in that region. Group ratings of “excellent,” “very good,” and “good” are derived … Read more

Health plans find themselves paying for the latest and greatest stent without any control over usage. Even bare-metal stents may be overused. Tom Pope Cal Weisberger, MD, buys stents as one of his responsibilities as regional chief of cardiology for the Southern California Permanente Medical Group. Yet he grapples with the need to purchase the … Read more

Diabetics receive better care in VA hospitals than they do in health plans, according to a recent study — but the implications are open for debate. “Our results suggest that a federally sponsored national health care organization can provide care that is equivalent to or better than that provided by high-performing commercial managed care plans,” … Read more

9 Ways To Reduce Unwarranted Variation When the approach in one town is major surgery and in another, it’s watchful waiting, you know there’s a problem. How Broadening DM’s Focus Helped Shrink One Plan’s Costs Blue Cross and Blue Shield of Minnesota and American Healthways score a hat trick by improving outcomes and satisfaction while … Read more

On the 1 hand, the More PCMH is a Commendable Attempt to gather in 1 place All the disorganized clinical and societal affirms the patient requirements. At precisely the exact same period, however, medical domiciles employ provider-defined small business models and traditional operation measures, belying that the patient-centered from the name. Founded in 2006, the … Read more

With the purchase of Concentra, a company that operates 300 clinics, the health insurer once again provides care When Humana recently purchased Concentra, a company that, among other things, operates 300 stand-alone clinics, the plan entered familiar terrain. Before becoming primarily a health insurance company in 1993, Humana was the nation’s largest for-profit hospital company. … Read more

Color chart On the whole, declines in HMO profitability have skidded to a near halt. Through the first nine months of 1997, the median HMO profit margin dropped slightly from 1996, but not anywhere near the dramatic losses posted in the previous two years, according to InterStudy Publications, which monitors HMO trends. In fact, half … Read more

Those with an entrepreneurial flair have taken aim at a problem that seems to have sneaked up on health plans: the cost of durable medical equipment. Just which patients should get motorized wheelchairs? How much can DME cost? Who knows what is a reasonable price for hospital beds, prosthetics, orthotics, incontinence products, and diabetes management … Read more

The managed care network shares new ideas about increasing patient satisfaction, reducing hospital admissions, and producing better outcomes overall Few health plans have the benefit of tracking their members for decades, let alone an entire lifespan. US Family Health Plan (USFHP), one of three managed care plan options under TRICARE, the system that provides civilian … Read more

The Chamber tracked down that the solicitation builds up a sensible premise to accept that violations under the ward of the ICC have been submitted in Afghanistan and that the necessities of gravity and complementarity have been met. Nonetheless, the Chamber discovered that opening an examination would not serve the interests of equity because of … Read more

A Conversation with Steven B. Epstein, J.D. This pioneering medical legal authority says health plans and physicians should stop fighting over scraps the government throws them. Steven B. Epstein, J.D., the founding member of Epstein Becker & Green, is a pioneer in health care law. Epstein, the senior health partner in the practice’s Washington, D.C., … Read more

In a stern warning issued to the health insurance industry, an Obama administration official says that the government won’t hesitate to block mergers that threaten to stifle competition. During a conference with the American Bar Association and the American Health Lawyers Association, Christine Varney, the Justice Department’s antitrust chief, said that enforcement of antimonopoly laws … Read more

Efforts are under way to find out exactly how pharmacy benefit managers work their magic In health care, pharmacy benefit management companies are the Wizards of Oz, the folks behind the curtain. As drug prices skyrocket, the companies promise health plans, employers, and the federal government magical savings, and they often deliver. Studies show PBMs … Read more

The CNN story once again puts controversy about prior authorization into the spotlight. But is it necessary to review the entire medical record? The controversy about whether a former Aetna medical director reviewed a patient’s medical record burned hot for a few days, put prior authorization into the news cycle, and then faded from view, … Read more

MANAGED CARE November 2005. ©MediMedia USA Good news for employers can be found in a study by Hewitt Associates that reports that health insurance costs increased by 9.2 percent this year. That’s the first single-digit increase since 2000. The report contained not-so-good news for employees. Their contributions to health care premiums increased 65 percent, from $877 per … Read more

January 2019 ePub January/February 2019 March 2019 April 2019 May 2019 June 2019 July/August 2019 August 2019 ePub September 2019 October 2019 November 2019 December 2019 Paul LendnerPaul Lendner ist ein praktizierender Experte im Bereich Gesundheit, Medizin und Fitness. Er schreibt bereits seit über 5 Jahren für das Managed Care Mag. Mit seinen Artikeln, die einen einzigartigen Expertenstatus nachweisen, liefert er unseren Lesern nicht nur Mehrwert, sondern … Read more

Both fee-for-service and capitation arrangements can bring favorable compensation levels, but mixing the two poses problems. By Karen L. Trespacz, J.D. Capitation versus fee-for-service payment: Which is better for physicians? Doing mostly one — either one — seems to work best. It’s trying to do a bit of both that causes problems. This is a … Read more

Deliver ‘medically tailored’ meals that take into account the nutritional needs of people with chronic illnesses. They will stay healthier and avoid expensive hospital care. You are what you eat. And you are healthy if you eat healthy. That’s the idea behind Community Servings. It tailors meals for the chronically ill. Ask David Waters, CEO … Read more

Too often, the prices of health care services and drugs are cloaked in mystery. A growing consensus demands that patients be given a clearer sense, in advance, of what things will cost. But there are obstacles–and some people benefit from the present confusion. “Your insurance doesn’t cover this medication, so we applied a coupon,” said … Read more

Disease Management Health Plans Are Ill-Prepared for Looming Diabetes Epidemic The problem is outpacing insurers’ resources and perhaps even their commitment. Can the chronic care model help? Martin Sipkoff Contributing Editor Diabetes is creating an escalating economic crisis for our health care system. Health plans use a handful of approaches, but “many insurers remain unaware … Read more

More vendors are turning to the Internet to expand the reach of programs. Cutting-edge technology helps patients help themselves. By Charles Downey As with any dynamic business, disease management is changing as it grows, relying more and more on the Internet as a tool to help lower the costs of caring for the chronically ill. … Read more

What happens when a group-model plan folds? It’s sink or swim for salaried physicians who never had to worry about the business side. UPHEAVAL IN ALBANY For the past 19 years, Gary Kronick, M.D., had few worries. His practice, set up just outside Albany, N.Y., offered everything he desired upon leaving Philadelphia’s Hahnemann University in … Read more

May 18, 2017     Laboratory evidence used to support efficacy The FDA has expanded the approved use of ivacaftor (Kalydeco, Vertex Pharmaceuticals) for treating cystic fibrosis. The approval triples the number of rare gene mutations that the drug can now treat, expanding the indication from the treatment of 10 mutations to 33. The agency based … Read more

Why pay through the nose for tomorrow’s high-tech cures when you can buy an inexpensive ounce of prevention today? As director of the University of Michigan Health Management Research Center, Dee W. Edington, PhD, has been measuring the effects of corporate attempts to help employees live healthier lives for three decades. He’s been called the … Read more

As premiums soar, the new Democratic majority weighs the benefits of restrictive regulation vs. the free market Medicare officials have consistently emphasized the positive about the Part D drug program, and they weren’t changing their tune going into open enrollment season for 2009. In a teleconference with reporters in November, acting Administrator Kerry Weems said … Read more

Cigna will have to pay back claims to between 600,000 and 700,000 physicians and other providers, according to a settlement the health insurer reached in a class-action lawsuit. Though Cigna has not admitted any wrongdoing, the outcome of the suit could wind up costing the company $200 million. Apparently, the company’s claims-processing program malfunctioned…. Prescription … Read more

Cancer is among the leading causes of disease and death from the U.S.. The American Cancer Society estimates that about 1.7 million new cases of cancer are diagnosed at the U.S. at 20171 and over 15 million Americans alive now have a cancer heritage. Does cancer require an immense toll on the wellbeing of Americans … Read more

There’s more than one way to skin a cat, but all are not equally good. Is it time for another look at managed competition? Martin Sipkoff Resourcefulness, fairness, and a feeling of déjà vu emanate from Professor Alain Enthoven’s managed competition model. His vision of large regional health plan exchanges that encourage competition among physicians … Read more

The Accession of Pembrolizumab into neoadjuvant and adjuvant chemotherapy reaches higher levels of pathologic complete response compared to placebo in patients using triple-negative breast cancer, based on results of this period III KEYNOTE-522 trial demonstrated at the 20-19 San Antonio Breast Cancer Symposium.1 some great advantages of pembrolizumab had been consistent across sub groups no … Read more

Employees, don’t be surprised when your annual explanation of employer benefits includes not only the 401(k) plan and 10 paid holidays but also a financial incentive program to better manage your health. A survey of 453 large employers found that half currently use incentives to encourage their workers to participate in health improvement activities such … Read more

The country’s elite cancer hospitals may be facing a less coddled existence. Fox Chase is getting ahead of the game with efforts to reduce readmissions. It’s on purpose and there’s a lot of history behind it, but the plain fact of the matter is that the rules that other hospitals have to live by don’t … Read more

Physicians and their charges have different ideas about what makes for good cancer care. Patient surveys help, but they need to be handled right. Patient-centered quality measures may be a “scary black box” to many physicians, says Colleen McHorney, PhD, one of the leaders of a study measuring patient expectations. What is quality in medical … Read more

The dominance of some health plans in many markets has placed physicians in an untenable bargaining position, the American Medical Association contends. The AMA is using a report that backs up that position in the hope of persuading the the U.S. Department of Justice to take a closer look at health plan mergers and acquisitions. … Read more

Things are far from rosy, but there is a rise in cooperation between plans and physicians. Can peace be far behind — or is it a lull in the fighting? Michael D. Dalzell Senior Editor Though pockets of “prepaid health care” existed long before 1973, this year really is the silver anniversary of managed care … Read more

At a glance California Consumer Health Scope http://www.healthscope.org Developer: Pacific Business Group on Health, San Francisco, regional employer health coalition Goal: Provide comparative data on health plans and hospitals, as well as general health care information, to consumers Strategy: Establish World Wide Web site, use employee newsletters to build awareness of site To encourage California consumers to think … Read more

By Frank Diamond Senior Editor Worrying about how you’re going to weather the next recession these days is a little like brandishing a prenuptial agreement at your engagement party. Nobody wants to think about a downturn while the economy is humming along. Maybe, as some experts suggest, it’s impossible for HMOs, medical groups or any … Read more

Voters in Oregon are likely to be asked to decide in November whether to ban capitation in the state. Viewed as a test case for other states, the drive is being led by Gordon Miller, a Salem ophthalmologist. More than 73,000 signatures are needed to place the initiative on the ballot, and so far about … Read more

BY JEAN LAWRENCE Contributing Editor How big a future does capitation have? One thing seems sure: Despite variations such as “contact capitation” that borrow its name while seeking to mitigate some of its blunt effects, capitation itself will be an enduring feature of the landscape. “Oh, no, it has not run its course,” exclaims Gary … Read more

A program to reduce medical errors promised providers that confidentiality would be protected. Then came a problem demanding immediate attention. Michael S. Victoroff, MD Sometimes confidentiality conflicts with patient safety. I would like to report a case of this in the context of a research project in which I was involved. And, I’m glad to … Read more

Medical literature has emphasized the requirement to watch patients’ liberty; nevertheless, not all experts accept this principle. In seriously ill patients, that particular specific battle includes the individual’s family and creates a distinct family-physician romantic romance. The objective of the review will be to check evidence on medical decisionmaking along with the family-physician romantic romance. … Read more

Population management claims: The Seven Rules of Plausibility provide means to test the claims of population management vendors. With case studies and commentary. Al Lewis President, Disease Management Purchasing Consortium About this article Al Lewis has been a thorn in the side of the disease management industry for years, and with his new book, Why Nobody … Read more

The journal Neurology’s release last month of a study on Alzheimer’s generated headlines across the United States because of the daunting conclusion: The number of patients with the disease will nearly triple by 2050. What didn’t attract as much attention, but will concern physicians and health insurers, is the researchers’ contention that there may not … Read more

Cancer of colon and Anus Has Become the next most Frequent form of Cancer at the USA in both gents and ladies. Approximately 21 percent of patients with pancreatic cancer have been diagnosed with metastatic disperse up on initial demonstration, and 50 percent to 60 percent of most patients with earlier period CRC will gradually … Read more

The legislative response to consumers receiving surprise medical bills after a visit to the hospital is likely to boil over in 2016 after simmering in 2015. The problem stems from the inability of health plans and out-of-network hospital specialty providers to agree on a proper fee, so consumers end up being billed the balance. Several … Read more

If UnitedHealth Group’s effort to buy a large physician group proves successful, clinical execs will have even more oversight People were caught off guard when UnitedHealth Group announced in early September that its OptumHealth services unit plans to buy Monarch HealthCare, a 2,300-physician group in California — people like Tommy Bohannon, vice president for hospital-based … Read more

Prescription benefit arrangements between physicians and managed care companies seem to be a growing trend replete with growing pains. In 1995, Harris Methodist Health Plan, the largest in northern Texas, informed the Fort Worth Clinic and its physicians that they were to spend no more than 9.6 percent of each premium dollar on drugs. If … Read more

In contrast to most created nations, the US doesn’t have a public wellbeing framework, and since Americans have the most costly framework on the planet, even a clinic outing can be monetarily ruinous. This is the reason health care coverage is such a need. Most Americans get protection one of three different ways: through government … Read more

By Now research On-screen time reaches the People, it Is Frequently Styled in Vintage terms: tips establishing strict time constraints, or news reports together with names such as”Are Screens Bad for children?” In Fact, though, display time research has been less than Definitive, chiefly because of deficiency of strong studies up to now. That is … Read more

A health plan saved $28.5 million by separating the service physicians perform in administering medical injectable drugs (MIDs) from the cost of the drugs themselves. Highmark, a licensee of the Blue Cross & Blue Shield Association, paid for the drugs and the doctors’ time and skill through the medical benefit. Historically, the plan used a … Read more

Family and general practitioners would do well to move their practices to Wisconsin, Arkansas, West Virginia, or Kansas. That’s because FPs and GPs in these five states get paid the most for this profession — especially when the cost of living is factored in. Cost of living applies to the average cost of basic necessities … Read more

Enteromedics’s Maestro Rechargeable System was approved when the FDA considered weight differences after the yearlong trial was officially over It doesn’t take much time in a public location to realize that Americans are fat! In fact, the percentage of Americans who are obese (the medical term) has been increasing for several decades. Recent data suggest … Read more

Everyone is afraid of being sued. Health plans don’t want to be sued by their physicians. Neither plans nor doctors want to be sued by patients. And so America’s zeal for litigation has emasculated one tool meant to provide accountability in health care: the hated National Practitioner Data Bank. The Office of the Inspector General’s … Read more

Sell medical health insurance with a decent quantity of physicians under contract. Frequently, the sole real power a single doctor comes in discussions with a managed care company is that the power to say”no more” to contract conditions which are unsuitable for clinical or fiscal motives. The insurer recognizes this ability and has begun to … Read more

In their relationships with vendors, employers all too often don’t set expectations for levels of service, adequacy of reports, or how performance will be measured. They are often left with the performance deemed appropriate by the vendor, which may not satisfy them or meet the needs of their employees. Warren Buffet once noted, “Price is … Read more

The very first generic naloxone hydrochloride nasal spray, also popularly called Narcan, a life threatening medication that could reverse or stop the results of an esophageal disorder. The bureau is also likely new measures to prioritize the record of additional generic medication applications for services and products intended to address esophageal disorder, together with the … Read more

Name Last modified Size Description Parent Directory 30-Sep-2000 10:40 – ../../../archiveMC/9711/QNA.1.GIF 17-May-2000 12:21 1k 9711.washington.shtml 17-May-2000 12:21 8k 9711.truthcap_chart3..> 17-May-2000 12:21 15k 9711.truthcap_chart2..> 17-May-2000 12:21 10k 9711.truthcap_chart1..> 17-May-2000 12:21 18k 9711.states.shtml 17-May-2000 12:21 8k 9711.qnaellwood.shtml 17-May-2000 12:21 32k ../../../archiveMC/9711/9711.outlook_charts.gif 17-May-2000 12:20 41k 9711.outlook.shtml 17-May-2000 12:20 1k ../../../archiveMC/9711/9711.outlook.pdf 17-May-2000 12:20 27k 9711.news.shtml 17-May-2000 12:20 7k ../../../archiveMC/9711/9711.medstat_chart.gif … Read more

New regulations taking effect in Colorado this month tighten reporting rules and seek to gain greater proof that health plans are delivering quality care. The regulations require plans to have written quality assurance programs to evaluate their services. The plans must detail the treatments and conditions that will be reviewed, and conduct research to improve … Read more

Positive results from a phase 2 study of enzalutamide (Xtandi, Astellas US/Medivation, Inc.) compared with bicalutamide in patients with metastatic castration-resistant prostate cancer have been published online in Lancet Oncology. The TERRAIN trial enrolled 375 patients in North America and Europe. The study enrolled patients with metastatic prostate cancer whose disease had progressed despite treatment … Read more

Improving Oral Pharmacologic Treatment And Management of Type 2 Diabetes Treating Psoriasis Patients With Biologic AgentsCase Study of a Failed Merger of Hospital SystemsBalancing the Health Care ScorecardManaging Perinatal Outcomes: The Clinical Benefit and Cost-Effectiveness of Pharmacologic Treatment of Recurrent Preterm LaborA Health Care Management Company’s Experience With Palivizumab – 1 Year LaterManagement of Moderate … Read more

MANAGED CARE June 2006. ©MediMedia USA Imagine an America where few businesses purchase health care for employees. Should that come about, the individual market will have new products ready. Lola Butcher If employer-sponsored health benefits go the way of the Model T, the big managed care companies in the Detroit market intend to be ready. In June, … Read more

All these are the exact fives countries that initially listened to this bargain and also were called as plaintiffs from the first criticism DOJ brought against CVS-Aetna within the almost $70 million merger. To ease this problem, DOJ reached a settlement deal with CVS and also Aetna that demanded Aetna divest most its Medicare Part … Read more

Another investigation discovers the utilization of moderate sedation, where patients needn’t bother with a breathing cylinder, prompts better clinical results when contrasted with general sedation for patients going through transcatheter aortic valve substitution (TAVR). Scientists from the Perelman institute of Medication at the College of Pennsylvania led the biggest observational investigation of insignificantly intrusive transfemoral—section … Read more

Michael D. Dalzell As anyone who has watched the field with some regularity knows, cancer immunotherapy is a tough field to hoe. Provenge is the only therapeutic vaccine for cancer to make it all the way to U.S. Food and Drug Administration approval, and it’s struggling to gain market share. Many more — see GVAX, … Read more

Product overcomes patent-infringement lawsuit Xtampza ER (oxycodone) extended-release (ER) capsules CII (Collegium Pharmaceutical, Inc.) has won full marketing approval from the FDA. The drug was awarded tentative approval in November 2015, but full approval was contingent on the outcome of a lawsuit filed by Purdue Pharma against Collegium. Purdue, which has developed abuse-deterrent versions of … Read more

The senate majority leader, a surgeon who owns a large stake in a chain of hospitals, puts forth far-reaching proposals for reforming the health care system. John Carroll See also: Mental Health Parity Must Wait Once Again ‘Tis the season of ambitious health care plans and a big, bright vision of the future. And with most … Read more

New Clinical Trial Will Test Cancer Drug as Alzheimer’s Treatment Nilotinib induces autophagy   The FDA has informed Georgetown University Medical Center that it may proceed with a phase 2, randomized, double-blind, placebo-controlled study of nilotinib (Tasigna, Novartis) as a treatment for patients with mild-to-moderate Alzheimer’s disease (AD). Nilotinib is a kinase inhibitor approved for … Read more

Accountable Care Organizations and Cultural-Area Variation Paul Terry One of the more audacious promises of the accountable care organization (ACO) movement is the idea that providers of medical services can play a larger role in improving a population’s health. It stems from a notion that health care financing reforms will move the focus of providers … Read more

MANAGED CARE July 2004. ©MediMedia USA John A. Marcille The problem of obesity is so vast, broad, and complex that it throws off images that seem at first to be its opposite, something like black holes, stars that absorb light. The intense media coverage over revelations concerning Mary-Kate Olsen’s eating problems is an example. Here is a … Read more

A recently issued brief from the Henry J. Kaiser Family Foundation seeks to characterize and analyze persons who frequently, or infrequently, use hospital emergency departments (EDs). The report, titled “Characteristics of Frequent Emergency Department Users,” found that frequent users, those who had four or more visits over two years, often belong to groups with greater … Read more

I See Smirking ACO Critics The Pioneer Accountable Care Organization (ACO) was an additional ACO model offered by Medicare, designed for groups that were already experienced in coordinating patient care across the care continuum. The shared-savings payment policy in this case is aligned with higher levels of both sharing and risk than that of the basic … Read more

Expect wellness efforts to explode in the next few years as companies, federal and local governments, unions, not-for-profit organizations, and others that sponsor benefits increasingly adopt the theory that poor lifestyle decisions that people make contribute greatly to health care costs. This is according to the Express Scripts report “9 Leading Trends in Rx Plan … Read more

Because readings in the clinic are unreliable and are a questionable guide to diagnosing and treating high blood pressure, self-monitoring deserves a look Imagine a world in which the most frequent reason for physician office visits went away — and you are imagining the future. Three medical associations recently issued new guidelines for home blood-pressure … 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

Portable interactive communications technology promises to influence health behavior as mere postcards and email messages never did. There will be big rewards for the health plans that figure out how to use it well. That ring you hear may be your health plan’s future. Number-crunching aside, health care is really a very intimate business, and … Read more

Capecitabine increased overall survival versus capecitabine at a subgroup analysis of patients with metastatic pancreatic cancer and systemic inflammation at the esophageal stage II re-cap study. We report results from two phase III studies, JANUS inch and also JANUS 2. The main end point has been OS. Results The two studies were conducted after having … Read more

Many employees struggle with basic health benefit terms, a Watson Wyatt Survey finds. The top challenge for 43 percent of workers is understanding what their health care plan covers. Less than half are comfortable explaining common benefit terms, such as copayment and deductible, to friend or coworker…. Old matches new when it comes to oral … Read more

The head of the National Committee for Quality Assurance says health plans want to encourage physicians in the never-ending quest for quality. Managed Care first interviewed Margaret E. O’Kane in 1997, her seventh year as president of the National Committee for Quality Assurance. Another seven years later, O’Kane, who holds a master’s degree in health … Read more

Pharmacy in managed care has edged its way forward as a major issue of the day, thanks in part to the long-overdue discussion of whether (and/or how extensively) to provide drug coverage for people in the Medicare program. The fact is, we rely increasingly on pharmacy to deal with health care problems and to forestall … Read more

Follow this link to PDF version More than 1 in 8 people changed their personal physician or other primary provider of health care last year. Personal preference was the most common reason. One in every five changed for reasons related to health coverage, but that’s down from 1 in 4 just four years ago — … Read more

The number of one-year waivers for limited benefit (mini-med) health plans continues to rise, reports the Department of Health and Human Services (HHS). The total was 1,168 at the end of March. HHS saw an increase in the number of applications for waivers at the end of 2010 because December 1 was the final day … 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 … Read more

As Rising and High prescription drug prices Are Still a Premier Issue for customers and policy makers, medication manufactures and middlemen from the supply platform. A brand new Schaeffer Center white newspaper Sheds light on an essential feature of the dilemma: it demonstrates that rising rebates required by PBMs are correlated with rising list prices … Read more

Proponents of consumer-directed health plans (CDHPs) have a new study to cheer about: A retrospective claims analysis from a large employer that introduced a CDHP, a point-of-service (POS) plan, and a preferred-provider organization (PPO) to employees in 2001 found that the CDHP was cost-neutral or saved money on pharmacy compared with the POS plan and … Read more

In theory, ACOs are groups of providers that band together to lower the cost of health while maintaining its quality by using various tools in the value-based care (aka population health) toolkit: care coordination, data analytics, avoidance of low-value services. But a study published in this month’s issue of Health Affairs possibly—it is open to several interpretations—paints a … Read more

John A. Marcille Sometimes, following the changes in health care is like trying to take in several tennis matches at once. You might wind up knowing who won, but you’d be hard-pressed to say how it happened. Employers want to shift more of the financial burden to employees — hence the growing interest in consumer-directed … Read more

The risk of newborns with jaundice getting a rare form of cerebral palsy is virtually nil if guidelines developed by the American Academy of Pediatrics (AAP) are followed. Yet the authors of a study in JAMA Pediatrics say the guidelines would benefit from some revision. High levels of the yellowish pigment bilirubin cause jaundice, but the condition … Read more

Is 34 Weeks an Acceptable Goal For a Complicated Singleton Pregnancy? Examining Costs of Chronic Conditions In a Medicaid Population Diabetes Disease Management in a Community-Based Setting Estimating Pediatric Primary Care Provider Visits In a Capitated Environment: Encounter vs. Claims Databases The Effect of Practitioner Compensation on HMO Consumer Satisfaction An In-Office Diagnostic Procedure To … Read more

In 2019, the individual community pharmacy business represented 35 percent of retail shops in the USA with a 73.7 billion market place, as stated by the National Community Pharmacists Association (NCPA)’s newly published 20 20 NCPA consume. The NCPA Consume is Published to deliver an yearly breakdown of the independent community pharmacy market. In addition, … Read more

MANAGED CARE October 2008. ©MediMedia USA Despite saving the patient some money, retail clinics have not reduced total medical costs, according to a study published in Health Affairs. And while their convenience, quick service, lower cost, and transparent pricing have won over consumers who use them, researchers from HealthPartners who reviewed utilization trends, patient mix, and cost … 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

Those who choose these plans tend to be more educated and dedicated to maintaining healthy lifestyles The Employee Benefit Research Institute recently went looking for what many hope to be one of the bulwarks of a new, cost-effective health care system — the “engaged consumer.” The institute found him in two relatively new benefit systems: … Read more

John Marcille Supply meeting demand isn’t always good. We watched for years as young doctors displayed less and less interest in primary care. They’re only human, after all. An income difference between primary care physicians and specialists that can be measured in hundreds of thousands of dollars is difficult to ignore. That’s why the point … Read more

In Times of decreasing funds and pharmaceutical break through situations, our value-assessing approaches have been extended to their own limits. Assessing value is extremely intricate. Current value-assessment techniques hazard neglecting essential facets, such as treatment length, funding impact, or perhaps the significance of combination treatments. Specially when coping with break through treatments within high-prevalence signs, … Read more

Directions and warning labels for some pharmaceuticals are starting to contain what the Wall Street Journal describes as “tailor-made ads” for patients who pick up prescriptions at the drug store. The paper reports that the number of pharmacies using such ads, so-called “health newsletters,” has increased from 3,000 to 17,000 in three years…. The push … Read more

A recent study indicates that more than 60 percent of drugs were preferred on two to four of the six California formularies evaluated. “We described how much variability there was exhibited between formularies. The more variability, the harder it is for doctors to act as agents on behalf of their patients,” says William H. Shrank, … Read more

What can Americans learn from the worldwide spread of managed care? The question assumes that overseas experience translates. It can. Michael D. Dalzell Senior Editor Stop us if you’ve heard this before: Medical inflation and utilization are out of control. Payers are looking for ways to rein in costs without sacrificing quality. The twist? This … Read more

MANAGED CARE June 2008. ©MediMedia USA Recovering from a kick in the gut from investors in the first quarter of 2008, plans are now looking for ways to adjust to a drop in employer-based coverage Martin Sipkoff Contributing Editor The industrialist Henry J. Kaiser said that trouble is only opportunity in work clothes. Today’s managed care executives … Read more

Over the past several years, changes in laws and regulations have encouraged greater plan participation and enrollment growth in the Medicare Advantage (MA) private fee-for-service (PFFS) market, according to “The Emerging Role of Group Medicare Private Fee-for-Service Plans” from the Henry J. Kaiser Family Foundation. Legislation such as the Medicare+ Choice program, created by the … Read more

John La Puma, M.D. At a time in which top-selling meds are referred to as “blockbusters” and videotaped pharmaceutical messages fill physicians’ mailboxes, it is still sex, drugs and rock and roll that sell. Especially drugs. According to the New York Times, Americans spent more money on “anti-ulcerants” last year–$6.2 billion — than on any … Read more

Multimorbidity in patients with HF advances the sophistication of attention. As the quantity and sophistication of medication remedies increase, the prospect of adverse events and drug-drug interaction also grows. The announcement offers a clinically important collection of medications that could result in lead to gastrointestinal toxicity, exacerbate inherent myocardial malfunction, or contribute to precipitation of … Read more

The field of personalized medicine has made significant progress with key discoveries like single nucleotide polymorphism and microarray/biochips. These advances will benefit plans, patients, the pharmaceutical industry, and society. Daniel Pucheril MD/MBA candidate at Thomas Jefferson University, Philadelphia Smiriti Sharma MD/MBA candidate at Thomas Jefferson University, Philadelphia Introduction The notion of individualism is strong within … Read more

Even the defendants and plaintiffs have Shifted sides from the latest Court Drama enclosing the ACA condition that health plans insure women’s contraception. Where when the plaintiffs took exclusion on ethical and religious motives, it reproductive and states rights groups that confirm certain conditions which are attracting the legal struggles. Trump’s government to offer companies … Read more

Florida will soon test a program that could provide competition for HMOs serving the Medicaid population. Other states are watching. Chart: Florida, physicians, and hospitals could do well under the PSN model Florida is to become a proving ground for direct contracting come Oct. 1, when Medicaid recipients in Dade and Broward counties will be … Read more

A month-long pilot test for accountable care organizations (ACOs) did reasonably well in demonstrating an ability to collect and submit information for the program, reports the program’s sponsor, the National Committee for Quality Assurance (NCQA). Ten health care organizations took part. Its purpose was to help the NCQA develop ACO standards designed to improve the … Read more

The Stark II regulations allow many forms of physician compensation, as long as they are “commercially reasonable.” But the ambiguity of the law may spur some concern among physicians, who must try to determine how that phrase will be defined. This requirement shows up under Stark II’s approvals of employment relationships, isolated transactions, space rentals, … Read more

The “right … to petition the government” has come a long way in over 200 years, and health care organizations are not shy in exercising it. Maureen Glabman “Those who are organized, have the most money, the most influence, the most mobilized memberships are the ones whose viewpoints are being most heard.” — Charles Lewis … Read more

The diverse Latino population requires insurers to understand that there is no cookie-cutter answer for successful medication management Martin Sipkoff Diabetes and other chronic diseases disproportionately affect the 15 percent of our population that is Latino. Because health plans play an important role in encouraging patient medication management, several national and regional plans are developing … Read more

Insurers are busy merging with retailers and providers in vertical integration deals after attempts at horizontal combinations hit antitrust roadblocks. While 2019 might not see the mega-mergers of 2018, “I don’t think it will be a slow year,” predicts Stephen Burrill, vice chairman and health care leader at Deloitte LLP. Much of the action is … Read more

Disruptive Innovation If they can adapt, payers will have far more power than fragmented physicians, other providers, employers, and patients to shape the new environment Stephen Wunker David Duncan While the health care policy debate in Washington continues to center largely on who is provided insurance coverage, managed care organizations know that the primary business … Read more

A coalition of employers, legislators, consumer advocates, health plans, and drug companies may bring about equal coverage Martin Sipkoff Contributing Editor The health care industry and the American people may be at a historic moment in the treatment of mental health and substance abuse. Congress is considering legislation that would “completely end insurance discrimination against … Read more

The expense of prescribed medication is really a top health policy dilemma at the USA, with 79 percent of people considering that the price of pharmaceutical medication is equally unreasonable and major parties introducing legislation directed at reducing medication expenses. Though a lot of this attention on this present argument is dependent upon the consequence … Read more

The overall effect on human health could be extensive and costly for payers, experts warn Martin Sipkoff Contributing Editor As the insurance entity responsible for the health of its members, health plans are actively involved in fighting the threats to public health posed by climate change. Several plans are making a commitment to reducing their … Read more

MP-101 Has Potential to Drastically Alter Disease Progression Mitochon Pharmaceuticals’ MP-101 has received an orphan drug designation from the FDA for the treatment of Huntington’s disease. The company said that MP-101–a mitochondrial targeted compound–has been shown to protect both spiny neurons and general neurons and minimize brain-volume loss in patients with Huntington’s disease. Combined, these effects … Read more

It looks like most players in health care — IT vendors excluded — will get what they want if a bill delaying the deadline for compliance with the Health Insurance Portability and Accountability Act’s electronic claims standards becomes law. At press time, the bill had passed both houses of Congress and was in a conference … Read more

An MIT-led collaboration is working on a pilot project on how to pay for Zolgensma—a $2.1 million gene therapy—in installments that are contingent on the drug living up to its curative promise. The details of a new way to pay for high-priced gene therapies are not quite nailed down. But payers, drugmakers, and others are … Read more

It’s hard to get a handle on whether the HMO industry is headed for brighter days — or still in the doldrums. Weiss Ratings reports that 47 percent of HMOs lost money in the third quarter of last year. Aggregate HMO profits were $69 million, down from $274 million during the first quarter; losses started … Read more

Specialty Care Works Hard To Assure Its Resurgence For now, consumers are willing to pay extra for direct access. How long that continues is linked to whether old practice habits can be broken. Frank Diamond Managed Competition: The Future, Not the Past There’s more than one way to skin a cat, but all are not … Read more

Having Pharmacists Review Drug Regimens Could Save Billions Medication-related health problems afflict many patients and waste billions of dollars in treatment. Consultant pharmacists say they can help, and now have figures to back up their claim. Michael D. Dalzell Smoking Cessation Therapy Cheap In the Long Run Are We Unmanaging Care? Responding to market pressures, … Read more

So Much Data, So Few IT Workers Submitted by Frank Diamond on Fri, 2013-03-15 07:29 Steve Jobs famously staked his claim at the intersection of technology and creativity. Health insurers are looking for the intersection of technology and benefits knowledge, but are not quite sure how to get there. Do you hire information technicians and … Read more

It perhaps raises more questions than it answers, but isn’t that the way any process to overhaul the health care system starts? Republican legislators yesterday unveiled aspects of what will come after Obamacare. President Trump in a contentious news conference yesterday took a shot at the ACA. “We’ve begun preparing to repeal and replace Obamacare,” … Read more

1 day after his government announced plans to terminate the obligations weekly, Trump said he’d dismantle Obamacare”detail by detail ” His most recent actions increased concerns regarding insanity in automobile insurance markets. The subsidies cost $10 billion annually and so were projected at $10 billion to 2018, in accordance with tax analysts. “so much because … Read more

The answer depends on whom you ask. A search of news archives turns up two reported experiments with reimbursement of physicians for e-mail communication with patients. In these cases, the most paid for a cybervisit is $25. But in a Deloitte & Touche survey, doctors thought that, on average, $57 would be a more desirable … Read more

Seventy-five percent of cancer drugs are covered by Medicare Part D plans, with regional MA-PDPs (Medicare Advantage prescription drug plans) covering 85 percent. Researchers at Avalere Health stratified the universe of cancer drugs covered by each Part D plan by contract type (local MA-PDP, regional MA-PDP, and stand-alone PDP). Prior authorization is the most common … Read more

So many movie titles, so little time. A New Jersey law expected to go into effect next month raises the age when unmarried young adults are no longer covered under parents’ insurance to 30 — the oldest in the nation. Failure to Launch comes to mind, but then one finds that the young adults do … Read more

Society must realize that health care resources are limited and then must use them rationally. Fairly, too? Medical ethicists believe the United States needs to have a forthright public debate about how to spend limited health care resources wisely. We simply can’t pay for everything, so we must — as a country — decide what … Read more

MANAGED CARE November 1999. ©1999 MediMedia USA TRUCE? Some HMOs may be more willing than you think to help financially troubled medical groups survive. A willingness to cooperate is key. Michael D. Dalzell Senior Editor San Jose Medical Group is an old hand in managed care. In 1972, it became the first physician group in California other … Read more