UPMC Health Plan gets a discount if a patient on Brilinta has a heart attack or stroke. The novel sweetener is that UPMC will lower the monthly copay for Brilinta from $45 to $10, which means the patient cost will be abo...UPMC Health Plan gets a discount if a patient on Brilinta has a heart attack or stroke. The novel sweetener is that UPMC will lower the monthly copay for Brilinta from $45 to $10, which means the patient cost will be about the same as it is for generic Plavix.
The law is supposed to keep physicians from unduly profiting from referrals. But CMS Administrator Seema Verma thinks that it "may prohibit some relationships that are designed to enhance care coordination, improve quali...The law is supposed to keep physicians from unduly profiting from referrals. But CMS Administrator Seema Verma thinks that it "may prohibit some relationships that are designed to enhance care coordination, improve quality, and reduce waste," and thereby become an obstacle to ACOs and value-based care.
The need for a strong pricing strategy is a foregone conclusion. Hospitals and health systems have a window of opportunity now to craft a thoughtful approach to pricing that avoids common pitfalls and ultimately creates...The need for a strong pricing strategy is a foregone conclusion. Hospitals and health systems have a window of opportunity now to craft a thoughtful approach to pricing that avoids common pitfalls and ultimately creates a competitive advantage in the market.
The U.S. rate is now higher than infant mortality rates in Antigua or Cuba. Furthermore, the overall U.S. rate masks significant disparities. The infant mortality rate of non-Hispanic black infants is 11.2 per 1,000 live...The U.S. rate is now higher than infant mortality rates in Antigua or Cuba. Furthermore, the overall U.S. rate masks significant disparities. The infant mortality rate of non-Hispanic black infants is 11.2 per 1,000 live births, which is comparable to the rate in Libya or Tunisia.
Change is happening on multiple fronts and at a faster pace than ever before. Stakeholders that ignore or minimize it will do so at their peril. To be clear, addressing organizational change or purpose internally, as wel...Change is happening on multiple fronts and at a faster pace than ever before. Stakeholders that ignore or minimize it will do so at their peril. To be clear, addressing organizational change or purpose internally, as well as external positioning today, is the more likely path to success.
The American College of Emergency Physicians pushes a payment model that would have ED doctors tracking patients for 30 days after discharge. CMS may adopt it for Medicare. Meanwhile, emergency medical groups interested...The American College of Emergency Physicians pushes a payment model that would have ED doctors tracking patients for 30 days after discharge. CMS may adopt it for Medicare. Meanwhile, emergency medical groups interested in participating will need to learn the ropes of care coordination.
When patients and their medical records are out of whack, it causes harm and wastes money. It gets worse when organizations try to share patient records. Even if two facilities share the same EHR system, match rates may...When patients and their medical records are out of whack, it causes harm and wastes money. It gets worse when organizations try to share patient records. Even if two facilities share the same EHR system, match rates may be as low as 50%. Privacy concerns makes this problem difficult to fix.
Several factors are at work. Group health insurance got more expensive when the ACA mandated essential health benefits and no-cost preventive care. Some small companies dropped coverage altogether, but now they are comin...Several factors are at work. Group health insurance got more expensive when the ACA mandated essential health benefits and no-cost preventive care. Some small companies dropped coverage altogether, but now they are coming back into the fold as the employment market has tightened up, say brokers. Starting fresh, they have a chance to consider self-insurance.
Insurers and some drug manufacturers are turning to the Institute for Clinical and Economic Review (ICER) as the arbiter of drug prices, especially as prices soar and value is sought. But questions persist about the cost...Insurers and some drug manufacturers are turning to the Institute for Clinical and Economic Review (ICER) as the arbiter of drug prices, especially as prices soar and value is sought. But questions persist about the cost-effectiveness calculations of the Boston not-for-profit and its dependence on QALYs.
The Emergency Triage, Treat, and Transport, or ET3, pilot would empower EMS crews to treat patients at the scene of a call (sometimes with the help of telehealth) or take a patient to an alternative site like an urgent c...The Emergency Triage, Treat, and Transport, or ET3, pilot would empower EMS crews to treat patients at the scene of a call (sometimes with the help of telehealth) or take a patient to an alternative site like an urgent care facility or a doctor's office.
A newspaper series and a state audit put a spotlight on PBM practices in Ohio. PBMs may not like it, but it seems that much more may come to light about what used to be an obscure corner of the business of American healt...A newspaper series and a state audit put a spotlight on PBM practices in Ohio. PBMs may not like it, but it seems that much more may come to light about what used to be an obscure corner of the business of American health care.
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 heal...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.
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,...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.
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...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.
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 als...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.
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....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?
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...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?
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 ins...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?
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 adjustmen...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.
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 pot...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.