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Managed Care

Amit Chhabra, Patrick F Fogarty, Bartholomew J Tortella, Dean Spurden, José Alvir, Margaret McDonald, Jennifer Hodge, Andreas M Pleil
PURPOSE: To identify international units (IUs) dispensed and consequent expenditures for standard half-life (SHL) versus extended half-life (EHL) recombinant factor VIII (rFVIII) replacement products in hemophilia A patients in a real-world setting. DESIGN: Two U.S. claims databases were analyzed. METHODOLOGY: Number of IUs dispensed and quarterly expenditures for rFVIII products were collected from the Optum Clinformatics Data Mart and Truven Health MarketScan Databases...
October 2018: Managed Care
Zachary Hafner
The market forces pushing health care to evolve from volume to value are intensifying. At the same time, the culture change, capabilities, assets, methods, and mindset required to redefine the health care paradigm are staggering. Unlike corporate initiatives, we simply can't get there thinking quarter to quarter. But we will get there.
October 2018: Managed Care
Maggie Alston, Bruce Pyenson
There are some valuable lessons for pharmaceutical manufacturers in provider alternative payment models (APMs), but whether pharmaceutical APMs succeed or fail will depend on finding solutions to operational and logistical challenges-some of which are unique to the pharmaceutical industry. Pharmaceutical APMs may require the collection of information beyond the claims data that many provider APMs depend on.
October 2018: Managed Care
Charlotte Huff
Multiple sclerosis is an on-again, off-again condition that vexes patients and their loved ones. The unpredictability makes is difficult to manage in all respects, especially with escalating prices wreaking havoc with the cost effectiveness of the medications used to contain the disease.
October 2018: Managed Care
Richard Mark Kirkner
With no experience in elected office, President Trump came into power with a thin bench. Many of the health care officials in his administration have been recruited from think tanks funded by the Koch brothers. And the Kochs and the president don't see eye to eye (to put it mildly).
October 2018: Managed Care
Timothy Kelley
Democrats think that they've got a winning issue. Sen. Bernie's Sanders Medicare for All bill is gaining backers, but expanding access to coverage by the public payer may be more practicable. Sander's is just one of a bunch of Medicare expansion plans. They all have pros and cons, a major con being how to pay for it.
October 2018: Managed Care
Thomas Reinke
Pharma says rebates are a primary driver of high drug prices because drug companies raise prices in response to payers' demands for rebates in exchange for preferred placement on their formularies. PBMs and payers object. They say the rebates they get from drugmakers are largely passed on to health plans and patients and save consumers billions of dollars in the form of lower premiums and copays.
October 2018: Managed Care
Maggie Alston, Bruce Pyenson
The alternative payment model (APM) is a nontraditional financial arrangement that rewards health care providers who deliver cost-effective, high-quality care. Now we are facing the possibility that pharmaceutical manufacturers and insurers will embrace APMs as a payment mechanism in some situations.
September 2018: Managed Care
Jennifer Bright, Mark Linthicum
The "waste-free formulary" under development by the Pacific Business Group on Health sounds promising, but ultimately may not deliver the impact to self-insured employers its creators are promising. The approach glosses over a critical question: What constitutes "high-value"? The definition of value plays a central role in determining the care that patients ultimately receive.
September 2018: Managed Care
Laurie Golemi Norman
HEIP stands for hospital efficiency improvement program. It is a legal contract outlining specific initiatives where physician-driven variance can be improved across specialties and departments. For organizations with a good strategy to reduce care variation, a HEIP can provide the jolt of incentive that generates real improvement.
September 2018: Managed Care
François de Brantes
For those who doubt the importance of transparency in price and quality to free the market, you just have to look behind the public curtain and observe the fierceness with which the opponents of transparency are trying to keep consumers in the dark.
September 2018: Managed Care
Jan Greene
And that means full scope of practice as primary care providers. Medical societies hate the idea and think that nurse practitioners need to be tethered securely to a physician office in order to ensure top-notch care. Nurse practitioners counter that they can help shore up primary care.
September 2018: Managed Care
Lola Butcher
Patient-reported outcomes measures (PROMs) use a patient's response to questions to measure health status. If they're going to catch on payers will need to incentivize use. So far, that's not happening. But clinicians who use PROMs for clinical decision making might be providing a valuable service.
September 2018: Managed Care
Joseph Burns
The United States is the world's biggest spender on health care by far. And what do we get for it? Not as much as we should. Our quality shortcomings are not for lack of knowledge: Stakeholders know what to do to close these gaps. So why aren't they doing it?
September 2018: Managed Care
Lola Butcher
The pay-for-value movement could justify rewarding-and punishing-doctors based on quality scores. PROBLEM: Hardly anyone likes the current ways quality is measured, especially physicians. Few believe that Medicare's Merit-based Incentive Payment System (MIPS) will clear things up. In fact, it might cause more confusion.
September 2018: Managed Care
Ed Silverman
With accumulators, the value of any copay assistance cards or coupons does not count toward out-of-pocket medicine costs that are applied toward deductibles. It's a cost-shifting tool that's facing pushback from patients, providers, and others saying that accumulators will hurt public health.
September 2018: Managed Care
Thomas Reinke
Sanofi and Regeneron's Dupixent (dupilumab)-which is already approved for atopic dermatitis-has an FDA action date of October 20 for its asthma indication. It will join Nucala, (mepolizumab), Cinqair (reslizumab), and Fasenra (benralizumab) as a monoclonal antibody approved as a treatment for the type 2 inflammation phenotype in severe asthma.
September 2018: Managed Care
Michael D Dalzell
For 169 ACOs, time is up to take on downside risk. This group-30% of all of those in the Medicare Shared Savings Program (MSSP)-are Track 1, upside risk-only ACOs and are nearing the end of their contracts with CMS.
September 2018: Managed Care
Richard Mark Kirkner
The National Guidelines Clearinghouse might be making a comeback. It's been contracted out to the ECRI Institute, a not-for-profit organization that conducts medical safety research. ECRI plans to have a version of the clearinghouse website up and running anytime soon, with plans for a full relaunch in 2019.
September 2018: Managed Care
Eric Lederhaus, Rebecca Sanders Fung
Integrated care models can foster the kind of collaboration that's needed to treat complex, multifaceted problems like chronic pain. They are among our best hopes for an alternative to the overuse of prescription painkillers that has caused so much suffering and early death.
August 2018: Managed Care
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