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 compla...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.
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 ne...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.
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 patient...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.
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...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.
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 c...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.
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 dru...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.
Genetic testing, when used prudently, can help physicians and patients make an informed treatment choice together. But when the DNA tests are marketed directly to consumers, they can place an undue burden on our already...Genetic testing, when used prudently, can help physicians and patients make an informed treatment choice together. But when the DNA tests are marketed directly to consumers, they can place an undue burden on our already overloaded medical system.
In any instance when unanimity embraces an idea, a thoughtful person might ask whether there's true agreement or perhaps just a cone of vagueness that accommodates a variety of opinions and lets eyes of the beholders see...In any instance when unanimity embraces an idea, a thoughtful person might ask whether there's true agreement or perhaps just a cone of vagueness that accommodates a variety of opinions and lets eyes of the beholders see what they want to see. With value-based care, it may be the latter.
By some counts misdiagnosis leads to up to 80,000 hospital deaths each year-and results in billions in wasted medical spending. Lack of feedback and miscommunication are among the causes. Researchers, advocates, and othe...By some counts misdiagnosis leads to up to 80,000 hospital deaths each year-and results in billions in wasted medical spending. Lack of feedback and miscommunication are among the causes. Researchers, advocates, and others are pushing for changes and "diagnostic excellence."
Recent mergers didn't quiet the growing frustration and concern employers, pharmacists, consumer advocates, state legislators, and some members of Congress have with the PBMs' lack of transparency. There are still so man...Recent mergers didn't quiet the growing frustration and concern employers, pharmacists, consumer advocates, state legislators, and some members of Congress have with the PBMs' lack of transparency. There are still so many questions, and getting answers anytime soon will be a chore.
The clinics range in size from a nurse who shows up in a mobile unit a few hours per week to a large-scale, full-service health clinic with multiple primary care providers and clinicians who can provide dental and vision...The clinics range in size from a nurse who shows up in a mobile unit a few hours per week to a large-scale, full-service health clinic with multiple primary care providers and clinicians who can provide dental and vision care.
The Service Employees International Union Local 32BJ three years ago named Mount Sinai Health System as a preferred provider for participants and started a direct contract for those needing hip and knee replacement surge...The Service Employees International Union Local 32BJ three years ago named Mount Sinai Health System as a preferred provider for participants and started a direct contract for those needing hip and knee replacement surgeries. In health care there are not many examples where each party succeeds. This is one of them.
In 1991, the world's second richest man griped about health care costs. Today, Sam Walton's Walmart empire is striking back with direct contracting. The retail giant is using centers-of-excellence contracts by which it p...In 1991, the world's second richest man griped about health care costs. Today, Sam Walton's Walmart empire is striking back with direct contracting. The retail giant is using centers-of-excellence contracts by which it pays high-value provider organizations to treat specific medical problems.
Unlike most payer-provider relationships, the parties took a go-slow approach. The plan was offered only to employees who worked in a subset of Walmart and Sam's Club outlets and lived or worked near Emory providers, and...Unlike most payer-provider relationships, the parties took a go-slow approach. The plan was offered only to employees who worked in a subset of Walmart and Sam's Club outlets and lived or worked near Emory providers, and Walmart did not set premium levels to incentivize workers to choose the Emory ACO.
Here we are in early 2019, and how quickly and firmly the FDA and the pharmaceutical industry will embrace RWE and its raw material, real-world data (RWD), remains an open question. If that embrace is ever to get beyond...Here we are in early 2019, and how quickly and firmly the FDA and the pharmaceutical industry will embrace RWE and its raw material, real-world data (RWD), remains an open question. If that embrace is ever to get beyond gestures and lip service, the FDA will need to change its rules and culture.
"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 so..."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."
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 ma...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.
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 imp...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.
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 clin...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.
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...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.