Insurance

Health plans, providers, and consumers have to collaborate in order to bring value, Craig Thiele, MD, chief medical officer at CareSource, said at the America's Health Insurance Plans' National Conferences on Medicare and Medicaid, and Dual Eligibles Summit.

The most recent Medicare Advantage and Part D program audits revealed that oversight of formulary administration is an area that health plans continue to struggle with, Sarah J. Lorance, vice president of Medicare Compliance at WellPoint, said at America's Health Insurance Plans' National Conference on Medicare and Medicaid and Dual Eligibles Summit in Washington, DC.

Plans designed specifically for disabled dual-eligible Medicare and Medicaid beneficiaries are not necessarily enough to reduce use of costly services, according to a new report from the Government Accountability Office.

Both Medicare and commercial insurers have raised the bar for molecular diagnostic companies, requiring them to show clinical utility to receive reimbursement for cellular tests designed to guide treatment in cancer, rheumatoid arthritis, and other diseases. An important new article in The American Journal of Managed Care reviews cases from a top Medicare contractor and outlines how to build the evidence to meet today's standards.

The Affordable Care Act will save hospitals a projected $5.7 billion in uncompensated care this year, according to a report released by HHS. Roughly three-quarters of those savings are coming from Medicaid expansion states.

So far, the recent failure of a high-profile bundled payment pilot in California has not slowed enthusiasm for the concept from CMS.

Since it appeared last week, the editorial in the September issue of The American Journal of Managed Care, "Is All ‘Skin the Game' Fair Game? The Problem With ‘Non-Preferred' Generics," has received comment in The New York Times, ProPublica, US News and World Report, and Mother Jones, among others. Commentators note that what Gerry Oster, PhD, and Co-Editor-in-Chief, A. Mark Fendrick, MD, uncovered in their brief survey of health plans is not just disturbing but possibly violates the Affordable Care Act's prohibition against discrimination based on pre-existing conditions.

Driven by a consolidation of offerings, the number of Part D prescription drug plans will decrease by 14% in 2015. While monthly premiums will decrease overall by 2%, there will be large premium variations.

The authors comment on the growth of drug plans with tiers for "non-preferred" generics, and argue that most are inconsistent with established principles of formulary design.

Out-of-plan medication use accounted for a small share of diabetes, hypertension, and hyperlipidemia prescriptions filled by Medicare Part D beneficiaries.

Putting various branded drugs in "non-preferred" tiers and charging higher copays for them has been used for a number of years to steer consumers to use less costly medicines by giving them "skin in the game." But authors writing for The American Journal of Managed Care are alarmed by the policies of some insurers that now have designated entire classes of widely used generic drugs "non-preferred," leaving many patients without any low-cost treatment options for their diseases.

During the second year of the program, Medicare accountable care organizations reported improvements in nearly all of the quality and patient experience measures, according to data reported by CMS.

A study published in the Annals of Internal Medicine, the result of a collaboration between CVS Caremark and scientists at the Brigham and Women's Hospital and the Harvard Medical School, compared patient adherence to brand name versus generic statins.

Kimberly Westrich, director for health services research for the National Pharmaceutical Council, explained why accountable care organizations should consider medications an essential part of condition management.

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Yesterday's government report that healthcare spending will start rising faster after a decade of historically slow growth raises questions: Will rising numbers of insured people drive the spending? Or are healthcare costs going up on their own? The answer is likely some of each, based on a look at trends within yesterday's report and a just-released study of spending by commercial health plans, published in The American Journal of Managed Care.

Implementation of payment reform, without a corresponding change to coverage, benefit, and other payment requirements, creates conflicting incentives that may nullify the intended aim of payment reform: to improve health outcomes, while saving costs.

Two recent policy announcements, one from Medicare and another from the US Preventive Services Task Force, signal a shift toward understanding that America's battle with obesity and diabetes is not only a medical but also a behavioral health problem, and must be treated as such.

Balancing health care tailored to the individual with a modern reimbursement scheme based on population health is the challenge that awaits the nation's healthcare system. Based on a study in The American Journal of Managed Care, it can be done, even among patients like seniors who use more healthcare than most.

This week's news that Aetna would be repaid $8.4 million after uncovering a questionable relationship between three clinics and a hospital has its roots in a well-known managed care reality: If you're treated in a hospital setting, it costs more.

AAFP Board Chair Jeff Cain, MD, of Denver, sent a detailed response to CMS Administrator Marilyn Tavenner, MA, wherein he outlined some specific AAFP suggestions for improving the 2015 fee schedule.

Hospice has long been seen as a solution to achieving both quality of care and cost control at the end of life. The arrival of Medicare Part D has raised concerns that some drugs are paid for twice, but efforts to fix the problem will shift some burdens on to Part D plans, according to The American Journal of Pharmacy Benefits.

In 2003, when President George W. Bush signed the major Medicare expansion that would establish prescription drug coverage, he called it "a promise, a solemn promise, to America's seniors."

The authors demonstrate the utility of distributed data models for reporting of local trends and variation in utilization, pricing, and spending for commercially insured beneficiaries.