News

The important role of Medicaid health plans in states where landmark healthcare reform efforts are under way is highlighted in a new report, Medicaid Health Plans: A Turnkey Solution for Expanding Health Insurance Coverage for the Uninsured. Sponsored by the Association for Community Affiliated Plans (ACAP), the report focuses on health plans in California and Massachusetts – two states breaking ground in expanding coverage to uninsured residents.

To define e-visits, CPT code 0074T was adopted in 2004, says Lynn Gonzalez Monson, director of health information technology for Blue Cross and Blue Shield of Florida. The code requires documentation of history, system review and complexity of medical decision-making similar to those for office visits and consultations, establishing a firm basis for review. Reimbursement is limited to established patients. The Florida Blues allowed payment for the code since its inception, even for fully insured clients, and have reviewed every case it has been billed.

With transparency becoming a given, pharmacy benefit managers (PBMs) have taken a new approach to marketing their services. The primary marketing/sales strategy for Express Scripts, headquartered in St. Louis, is direct sales with a reliance on intermediary consultants and advisors.

Today, hospitals and other facilities are implementing forms of pay for performance in previously unimaginable ways. Such programs typically use established ratings methods and indicators to measure levels of quality, then offer incentives or compensation to entities or providers who are rated highly based on these indicators.

An effective use of hospitalists is to have them available to free up general practitioners from hospital rounds. Appropriate use of hospitalists can also enable physicians to visit patients more than once a day in the hospital setting.

Regardless of the structural framework of any nation's healthcare system, a critical measure of its success will depend upon the aligned incentives and objectives of its key constituents.

Pharmacy Benefits Managers (PBMs) have long gotten a bad rap, taking heat for lack of transparency in their dealings with pharmaceutical manufacturers. Some agreements leave health plans in the dark about the true value of their PBMs. Touting benefits, from clinical-based formularies and lower drug costs and to specialty pharmacy benefits and retail networks, may not be enough today to attract business in a competitive marketplace.

Ambulatory Surgical Centers (ASC) represent an unparalleled snapshot of the evolution of healthcare delivery, experts say. The surge in growth of ASCs nationwide affords patients the opportunity for non-emergent surgical and procedural services outside the hospital structure while also yielding cost-effective benefits for managed care organizations.

Earlier this year Susan Andrews, MD, evaluated a broken arm for a long-time patient in her family practice. Without leaving her Memphis office, Dr. Andrews conducted a complete history, assessed the injury and arranged a referral to an orthopedist, even though the patient was actually 2,000 miles away vacationing in the Caribbean.

Private sector organizations are pitching the government on new business, such as the recently embraced special needs plans (SNPs), designed for the costliest populations of seniors. Prompted by the Medicare Modernization Act, there are three SNP models: dual-eligible, institutional care and chronic condition.

As employers search for ways to reduce rising healthcare costs and improve employee productivity, more companies are implementing wellness programs in an attempt to improve employees' health and reduce their own insurance costs. There are a number of different options employers may consider when deciding to institute a wellness program, including offering smoking cessation and weight loss programs, fitness classes, and in some cases, penalizing certain behavior. Employers must be careful, however, to ensure that these programs do not violate certain federal and state laws as they carry certain inherent legal risks.

Pressure is mounting on Capitol Hill once again to ax payments to Medicare Advantage plans. The legislators need to save $10 billion in order to rescind a planned cut in Medicare rates for physicians by year-end. Conveniently, the Congressional Budget Office (CBO) estimates that equalizing payments between MA plans and fee-for-service Medicare will save $50 billion over five years. If Congress wants to expand the State Children's Health Insurance Program (SCHIP) and keep physicians happy, "excessive" MA rates are the prime target.

Dallas-Recently released results of a consumer survey show that a majority of Americans believe more emphasis on preventive medicine is a solution to the increasingly evident problems of the nation's healthcare system.

As the abundance of cliches would indicate, incentives are a powerful force. Health incentives, however, are becoming more sophisticated, and stakeholders need to adopt programs that work.

National Reports-The handful of health plans that represent the largest number of enrollees are publicly traded and therefore likely to have reported salaries and bonuses at the high end of the scale. However the majority of HMO chief executives are not part of these plans, industry experts say.

Washington, D.C.-In the latest salvo against private health plans, Congressional leaders claim that the Medicare Part D drug benefit raised costs for taxpayers and seniors some $15 billion this year due to higher administrative and sales costs and lower rebates from drug companies.

Actor George Clooney was hospitalized recently after a minor motorcycle accident. He cracked a rib, but that wasn't the worst of it. Star-struck hospital employees who weren't involved in his care accessed his medical record, no doubt hoping to find some celebrity gossip.

Patients with early-stage pulmonary arterial hypertension (PAH) and those with either inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or inoperable or post-pulmonary endarterectomy pulmonary hypertension can benefit from treatment with bosentan, according to study results presented at the European Society of Cardiology Congress 2007 in Vienna, Austria.

Thrombolytic therapy with reteplase/abciximab before percutaneous coronary intervention (PCI) (facilitated PCI) has no effect on post-myocardial infarction (MI) complications, including death, but the treatment significantly increases the risk of bleeding compared with primary PCI performed with in-lab abciximab in patients with ST-elevation MI, according to the results of the Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events (FINESSE) study.

In a multicenter, multinational, randomized controlled study, a fixed-dose combination of perindopril/ indapamide was associated with a reduced risk of death and vascular events in patients with type 2 diabetes, many of whom were already taking antihypertensive drugs.

The 2007 Congress of the European Society of Cardiology attracted nearly 30,000 attendees to Vienna, Austria, from September 1 to 5, 2007. The congress offered details of the latest research in various fields of cardiology

Maraviroc is the first CCR5 antagonist approved for the treatment of HIV-1 infection. The use of maraviroc is associated with significant decreases in HIV viral load and increases in CD4 counts in antiretroviral treatment-experienced patients with CCR5-tropic virus when used as an add-on to optimized antiretroviral treatment. In clinical trials, patients with dual- or mixed-tropic virus (which can infect cells using CXCR4 and/or CCR5 receptors) who were treated with maraviroc demonstrated no difference in HIV viral load compared with patients who received placebo. A recent study compared maraviroc plus lamivudine/zidovudine with efavirenz plus lamivudine/zidovudine; maraviroc did not demonstrate noninferiority when undetectable virus was defined as <50 copies/mL; however, maraviroc did meet noninferiority criteria when undetectable virus was defined as <400 copies/mL. Maraviroc is not recommended for patients with CXCR4-tropic, dual-tropic, or mixed-tropic virus; for antiretroviral-naive patients; or for..

An extensive systematic review published in the Annals of Internal Medicine demonstrated that older oral drugs for type 2 diabetes are just as, if not more, effective than newer agents for gylcemic control, lipid control, and other intermediate end points.

Angiotensin II receptor blockers (ARBs) have been demonstrated to reduce morbidity and/or mortality in patients with chronic heart failure (CHF), acute myocardial infarction (AMI), type 2 diabetes, and hypertension. Although as a class ARBs share a common mechanism of action, potency among the agents varies. Higher-potency ARBs (candesartan, irbesartan, olmesartan, and telmisartan) may demonstrate improved 24-hour blood pressure control, suggesting that these agents may have superior clinical event reduction potential versus lower-potency agents (eprosartan, losartan, and valsartan). We conducted a meta-analysis of randomized, controlled trials that evaluated the effect of ARBs on clinical outcomes. A systematic literature search of MEDLINE from 1966 through December 2006 was conducted using specific search terms. Studies that met the following criteria were included: randomized; not angiotensin-converting enzyme (ACE) inhibitor-controlled; incorporation of monotherapy with ARBs in 1 or more of the treatment..

First-time generic approvals: Carvedilol tablets; famciclovir tablets

The latest FDA action (through October 2007) related to valrubicin (Valstar), pancrelipase (Creon), raltegravir (Isentress), mifamurtide (L-MTP-PE, formerly Junovan), recombinant human antithrombin (Atryn), picoplatin, T4N5 liposome lotion (Dimericine), oral azacitidine, ANX-510 (CoFactor), vincristine (Marqibo), sorafenib (Nexavar), bendamustine (Treanda), MB07133, ALS-357, and MGCD0103

FDA has approved a new indication for risperdal. The drug is now indicated for the treatment of schizophrenia in adolescents aged 13 to 17 years and for the short-term treatment of acute manic or mixed episodes associated with bipolar I disorder in children and adolescents aged 10 to 17 years.

FDA has approved Somatuline Depot, an analog of natural somatostatin, for the treatment of acromegaly

What if MCO payers could measure providers' costs and outcomes in a single top-down program? What if they could standardize regulations, and immediately test their effectiveness? What if payers could actually help facilities and providers strike a balance between business efficiency and quality patient care-without shutting anyone down?

Today's standard of care has morphed from comprehensive to catastrophic care. As the number of uninsured Americans has increased, so has the percentage of emergency room cases that aren't emergencies. As many as one-half of ER patients are there for routine treatment because they have nowhere else to go.