Insurance

While formularies should provide physicians the ability to treat any patient that walks into the office, there also need to be clinical exceptions that allow patients with mitigating circumstances to get any product clinically necessary.

Despite studies suggesting higher spending levels do not necessarily produce better health outcomes, a new paper to be published in the Journal of Political Economy found the opposite to be true with regard to emergency care.

A one-minute look back at the week of February 2, 2015, in managed care, including another top resignation from a federal agency and budget proposals affecting Medicare and Medicaid.

The National Association of Accountable Care Organizations has teamed up with physicians, hospitals, medical associations, and almost all Medicare Shared Savings Program accountable care organizations in the country to pen a 36-page letter to CMS.

Following an announcement that Medicare would cover preventive low dose computes tomography for lung cancer screening, CMS released a final national coverage determination today that includes details on eligibility criteria.

The Medicare STAR medication adherence measures exclude diabetes patients at high risk for poor cardiovascular outcomes, and underestimate the prevalence of medication nonadherence in diabetes.

More than 400,000 Medicare beneficiaries who may have been confused or misinformed about the pharmacy details of their 2015 Aetna prescription drug plans have until the end of this month to find participating pharmacies or switch plans, according to CMS.

The President's budget proposal for 2016 seeks to gain the ability to negotiate drug prices under Medicare Part D, which will definitely face resistance from the Republican-controlled Congress.

A one-minute look back at the week of January 26, 2015, in managed care, including anticipated moves from volume-based to value-based payments and expected push back on cancer drug costs.

After calls for changes and more flexibility from physician groups, CMS announced it intends to modify requirements to meet meaningful use in the Medicare and Medicaid Electronic Health Record Incentive Programs.

A new health policy issue brief from the Brookings Institution has outlined specific modifications that would enable to legislation in Congress to support better care and more value in Medicare.

OIG recommends training for inspectors and amending contracts with stand-alone pharmacies to ensure improved quality and safety.

HHS has announced goals and a timeline to move Medicare toward a quality-based payment system and away from the current fee-for-service payments.

A federal lawsuit accuses the Cleveland Clinic Health System of performing more tests and procedures on patients than necessary in order to obtain more Medicare payouts.

Medicare is giving bonuses to a majority of hospitals that it graded on quality, but many of those rewards will be wiped out by penalties the government has issued for other shortcomings, federal data show.

The new Republican chairman of the Senate Finance Committee says the GOP will chip away at Obamacare "piece by piece." Still, he says he will work with Democrats to continue funding for the Children's Health Insurance Program and overhauling Medicare pay for doctors.

Obama administration officials have warned that ambitious experiments run by the health law's $10 billion innovation lab wouldn't always be successful. Now there is evidence their caution was well placed.

Medicare payments for hospice care carried out in an assisted living facility more than doubled from 2007 to 2012, raising questions about the incentives that Medicare provides for hospice care.

The aging US population means that Medicare is taking care of more older, sicker people for longer periods of time. Population trends suggest this phenomenon will only increase, unless drastic management and healthcare delivery solutions are found.

The combination of 2 Medi-Cal primary care rate decreases could mean primary care providers who see a lot of Medi-Cal patients will have to scale back or stop seeing those beneficiaries.

Although infection prevention programs require ongoing investments, the money spent is worthwhile considering the costs saved as healthcare-associated infection rates fall, according to a study in the American Journal of Infection Control.

The 4 private companies that run Medicare's recovery audit program will have their contracts extended through 2015. But it's unclear what types of medical reviews or claims are going to be eligible for auditing.

Of the many benefits that come from achieving a 4-star CMS rating or better, retention and growth are probably the biggest ones, according to Snezana Mahon, PharmD, senior director Medicare solutions at Express Scripts.

With 2014 coming to a close, The American Journal of Managed Care is taking a look back at the most popular articles from this year. These most-read articles highlight the healthcare issues most important to providers, insurers, and policy makers.