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JOURNAL ARTICLE
Frank Diamond
"The private sector will play an important role in the 10-year time frame. Patients are downloading their data from patient portals and sharing their information between their specialists. Provider groups and clinical societies will become more adept at using data to inform care pathways."
March 2019: Managed Care
#42
JOURNAL ARTICLE
Erik Johnson
As plans and providers collaborate to manage post-discharge care, they will also need to take heed of the nonclinical variables. Limitations in performing activities of daily living (ADLs) and social determinants of health (SDOH) have as great an impact on health care spending among the elderly as the presence of chronic conditions.
February 2019: Managed Care
#43
JOURNAL ARTICLE
Carrie Cowdin
Members are looking for a customized health care experience. With analytics, health plans can deliver it. Three key areas will help plans to close gaps in care and improve outcomes. They are: identifying at-risk members, tailoring communications and care settings, and increasing member motivation.
February 2019: Managed Care
#44
JOURNAL ARTICLE
John S Linehan
Drug manufacturers have relied on coupons to promote access to branded drugs by reducing patients' out-of-pocket costs. Insurers and PBMs, on the other hand, have opposed coupons because they undermine the effectiveness of cost-sharing requirements and benefit designs that incentivize cost-effective drug prescribing and purchasing choices.
February 2019: Managed Care
#45
JOURNAL ARTICLE
Sanjiv Luthra, Danny Sands
The problem of nonadherence must be addressed. We must improve the sharing of a patient's real-time medication compliance with care teams so that they are able to intervene in the right way at the right time. We must also educate patients. Medications can't be effective if people don't take them.
February 2019: Managed Care
#46
JOURNAL ARTICLE
Jan Greene
The Commonwealth Fund reports that U.S. women have more chronic illness, are less satisfied with their care, and have more trouble affording it-often skipping needed care because of cost-than women in comparable nations. Could universal coverage be the cure?
February 2019: Managed Care
#47
JOURNAL ARTICLE
Jan Greene
Hormone replacement therapy (HRT) has been around since the 1960s to help menopausal women who struggle with symptoms caused by the ebbing of estrogen. In 2002, a major study said that HRT could raise cardiovascular and breast cancer risks. Enter compounding. Too risky?
February 2019: Managed Care
#48
JOURNAL ARTICLE
Joseph Burns
Let the good times roll! CMS overpays for MA coverage, and that allows insurers to give enrollees extra benefits that traditional Medicare does not cover. But there's this thing called "politics," with rumblings that insurers have too sweet a deal. Will the spigot be turned off?
February 2019: Managed Care
#49
JOURNAL ARTICLE
Timothy Kelley
Is Medicare Advantage a ripoff of taxpayers, a godsend for integrated, cost-effective care, or somehow both? Contributing Editor Timothy Kelley walks you through the details of quality star ratings, preliminary adjustments, the quartile system, regional plans, risk scores, coding intensity adjustments, and rebate percentages.
February 2019: Managed Care
#50
JOURNAL ARTICLE
Michael D Dalzell
A report from the Washington Health Alliance looks at 48 treatments, tests, and procedures identified by the Choosing Wisely campaign as having little clinical benefit in certain circumstances and, in many cases, the potential to cause harm.
February 2019: Managed Care
#51
JOURNAL ARTICLE
Richard Mark Kirkner
Step therapy is common in commercial insurance but new to MA. Insurers defend it as an evidence-based way to put some guardrails on ill-advised, costly prescribing. Practitioners, medical societies, and drugmakers complain, though, that CMS's guidance is vague, and gives plans too much latitude in dictating step edits.
February 2019: Managed Care
#52
JOURNAL ARTICLE
Peter Wehrwein
Lyman has emerged as an important voice about biosimilars and their potential for corralling cancer costs. It's personal because Lyman is all too aware of how the price of medications can ruin patients financially. We need more biosimilars on the market, he contends.
January 2019: Managed Care
#53
JOURNAL ARTICLE
Thomas Reinke
The FDA's approval criteria require a biosimilar to be highly similar to its original biologic and show "no clinically meaningful differences." But mere similarity is not close enough for many clinicians and some patients; it makes biosimilars seem riskier than the original biologics.
January 2019: Managed Care
#54
JOURNAL ARTICLE
Thomas Reinke
Companies with originator biologics on the market have used a variety of regulatory and legal tricks to fend off biosimilars and keep the revenue generated by their products pouring in. The most common approach has been for the "originators" to take legal action to assert or defend the patents attached to their products.
January 2019: Managed Care
#55
JOURNAL ARTICLE
Susan Ladika
It's the best-selling drug by revenue worldwide and manufacturer AbbVie has worked hard to fend off competition. Very hard. Humira faces competition in Europe, but it will probably take years before its market share is challenged in the United States.
January 2019: Managed Care
#56
JOURNAL ARTICLE
Richard Mark Kirkner
The FDA commissioner has an 11-step "action plan" to get biosimilars out of a repeat mode of unrealized potential. But issues like interchangeability still need clarifying if biosimilars are to have a major effect on drug expenditures.
January 2019: Managed Care
#57
JOURNAL ARTICLE
Jesse Ford
Having a payer collaboration leader is especially important for large health systems that have yet to fully consolidate revenue cycle operations following a merger or have far-flung operations in multiple states. They may vary in some details, but the same payer issues tend to crop up across a health system.
December 2018: Managed Care
#58
JOURNAL ARTICLE
Emad Rizk
The past decade has seen advances in payer-provider collaboration and data sharing that reflect clinical, economic, and administrative alignment. What's needed now is a deeper level of commitment to drive sustainable improvements in quality and cost.
December 2018: Managed Care
#59
JOURNAL ARTICLE
Richard G Stefanacci, Terri Schieder
Population health service organizations (PHSOs) are supplanting management service organizations that gained popularity in the '90s. PHSOs are emerging as the organizations within health systems that can improve the clinical and financial outcomes of the populations the health systems serve.
December 2018: Managed Care
#60
JOURNAL ARTICLE
Petra Esseling
Despite high need and urgency, patient adherence is low. One might think that puts the onus on patients, but a major reason for this gloomy picture is the severe shortage of mental health professionals across the country-a shortage that's only going to increase.
December 2018: Managed Care
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