Understand choice, implications of law principles
December 1st 2007Choice of law issues arising from coverage disputes of both individual and group insurance policies many times determine which party will prevail on the merits of a particular case. Also, in today's mobile economy, insurance transactions frequently cross state boundaries.
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Consumer-driven pharmacy plans must focus on compliance and safety
December 1st 2007A recent survey by the Employee Benefit Research Institute found that 70% of those enrolled in consumer-directed health plans (CDHP) say that they consider costs when deciding to see a doctor or filling a prescription as compared with fewer than 40% of those in a comprehensive plan. However, the survey also found that CDHP enrollees were twice as likely to avoid, skip or delay healthcare services.
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Medicaid health plans are critical to covering the uninsured
November 1st 2007The 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.
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Market pharmacy programs by highlighting value
November 1st 2007Pharmacy 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.
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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.
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Monitor discrimination laws for wellness programs
November 1st 2007As 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.
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Attack mounts on high payments to Medicare plans
November 1st 2007Pressure 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.
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Relevant rewards: Incentives inspire healthy behavior, but be prepared to invest and innovate
November 1st 2007As 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.
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Managed care CEO salaries rise on par with private industry
November 1st 2007National 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.
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Democrats blast costly Medicare benefit
November 1st 2007Washington, 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.
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Focus on fundamental right to healthcare for all
October 1st 2007Today'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.
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CDHC onus falls on health plans
October 1st 2007Consumers tend to seek the best combination of price, features and quality when shopping for medical services, just as in other market transactions. Today, employers are relying on health plans to fill the value-information void with Web-based decision support tools.
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Policy empiricist: Law Professor David Hyman examines progress of state leadership
October 1st 2007If you ask David Hyman, Cato Institute adjunct scholar and University of Illinois professor of health law and medicine, what's on the horizon for healthcare, he'll tell you he'd rather share his empirical view of what we've learned from the past instead.
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Managed Healthcare Executive recently surveyed readers and gathered your predictions for some of managed care's biggest issues in 2008, including drug safety, technology integration and competition. Answers from the more than 500 respondents indicate that an increasing number of you are uncertain about what the next year will bring, but you remain optimistic about your opportunities and your core capabilities. Comprehensive indicators suggest that the industry is becoming more granular, that is, more customized and more focused on one-off strategies, further stratified populations and differentiation in the market. Preparing for another year of regulatory changes, political influence and industry self-governance will clearly call for greater collaboration, which is another recurring theme throughout this Special Report. We've also included in-depth analysis from an authoritative panel of experts to help you forecast the turning points for 2008.
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Part D brings more drug coverage to seniors
October 1st 2007There has been a lot of good news about the Medicare drug benefit lately. Surveys show a substantial increase in coverage, particularly among low-income seniors. Costs are less than expected; employers continue to offer retiree benefits; major insurers are sticking with the program; and product coverage remains fairly broad. Beneficiaries seem generally satisfied with the program, and the much-feared "donut hole" appears less lethal than anticipated.
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Few can design truly affordable coverage
October 1st 2007Every time I look through the sales fliers in the Sunday newspaper, I'm amazed by all the stuff we can buy. Toys, such as satellite radios and video game systems, are just the beginning. Today, you can even buy high-end cleaning products for your bath or shower at more than 10 times the price of a simple sponge and some cleanser.
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Health insurance premiums hold steady, but future hikes likely
October 1st 2007Washington, D.C-Employer-sponsored health-insurance plan premiums increased only 6% in 2007, less than the last four years. However, insurance costs are rising much faster than inflation and wages, according to a leading survey of employer health benefits. Premiums now average more than $12,000 for family coverage (almost $4,500 for individuals), pricing many workers out of the market.
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McClellan seeks to lead charge for healthcare reform
September 1st 2007WASHINGTON, D.C.-Instead of going back to academia, former FDA Commissioner and Medicare Administrator Mark McClellan, MD, is setting up his own shop to tackle health reform and drug safety more actively. Dr. McClellan will head the Engelberg Center for Health Care Reform at the Brookings Institution, starting with $20 million in funding from Alfred Engelberg and Leonard Schaeffer.
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Integrated approach to Medicare Advantage may spell difference between profit and loss
September 1st 2007Leaders of Medicare Advantage (MA) organizations are concerned about maintaining the profitability of their MA products. To be successful, organizations should develop internal profitability best practices.
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Future of U.S. managed healthcare centers on simplicity and ease of use
September 1st 2007Healthcare reform has surfaced as a national topic. Intel co-founder Andy Grove outlined some noteworthy ideas on healthcare reform during a national speaking tour, and California Governor Arnold Schwarzenegger recently proposed a plan to cover the citizens of his state. Getting a head start on the 2008 Presidential race, Mitt Rommey is weighing in with proposals based on his experience as former Governor of Massachusetts. While all these ideas are coming from different sources, they all share a few basic themes: healthcare should be easy to find, to buy, and to understand.
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McClellan seeks to lead charge for healthcare reform
September 1st 2007WASHINGTON, D.C.-Instead of going back to academia, former FDA Commissioner and Medicare Administrator Mark McClellan, MD, is setting up his own shop to tackle health reform and drug safety more actively. Dr. McClellan will head the Engelberg Center for Health Care Reform at the Brookings Institution, starting with $20 million in funding from Alfred Engelberg and Leonard Schaeffer.
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Chronic care crossroads: AAN CEO hopes to swing policy pendulum in favor of prevention
September 1st 2007Pat Ford-Roegner, MSW, RN, FAAN, CEO of the American Academy of Nursing (AAN), seems a natural fit for her latest appointment as a member of the new Washington, D.C.-based Partnership to Fight Chronic Disease (PFCD) Advisory Board. The board, led by Richard H. Carmona, MD, MPH, FACS, former U.S. Surgeon General, is comprised of 40 high-profile CEOs and presidents from the public and private sector.
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Safety & Science: FDA Commissioner Andrew von Eschenbach looks to science and information technology
August 1st 2007Providing patients with safe, effective and affordable prescription drugs is a continuous challenge for health plans and insurers. These efforts rely heavily on the decisions made by the Food and Drug Administration (FDA) in determining which new drugs come to market and how those medicines perform when used in real-world healthcare settings.
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Corrective action plans play integral role in Medicaid suit
August 1st 2007Ahearing before a federal district court this summer will most likely conclude the 14-year Texas class action case of Frew v. Hawkins. This class action suit was filed in 1993 by a group of mothers who were dissatisfied with the medical treatment that their children received-children who qualified for, but allegedly did not receive, full preventive care and treatment under Medicaid laws. As states enact changes to ensure full compliance with these laws, MCOs will see the effects on Medicaid provider networks, reimbursement rates and reporting requirements.
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