Practice Management

We asked the Managed Healthcare Executive editorial advisory board: “What is your New Year’s resolution and how do you plan to achieve it?” Here’s what they said.

Unlike a traditional formulary, the value-based formulary emphasizes the clinical effectiveness of a drug rather than cost so that if a drug is very effective but expensive, it might still fall on tier one.

From Blue Shield of California's recently-announced purchase of a Medicaid plan to Partners HealthCare's hard-fought effort to fold more hospitals into its Massachusetts health system, the volume of mergers and acquisitions in the healthcare sector has steadily climbed and now exceeds M & A activities in all other U.S. industries. The surge is being fueled by payers and providers seeking new business opportunities in the post-ACA healthcare market, and 2015 is on track to be another record-breaking year.

Envisioning a public health threat, managed care recently notched up its readiness for an Ebola outbreak in the United States. Valuable lessons emerged from the latest effort, adding to the knowledge gleaned from other epidemics, such as the HIV/AIDS and SARS viruses and the bird flu.

Nearly a year after two medical societies released a national consensus statement on the safe prevention of certain C-sections, broad consensus seems to boil down to this: Steps must be taken to lower C-section rates in the U.S., and strong outreach to ob/gyns is critical for success.

More than $23 per member per month saved when coaches offer remote assistance

Recent studies on diabetes control are wrangling for attention with some confirming the National Health and Nutrition Examination Survey (NHANES), which suggests that diabetes control declined through the late 1990s, while others indicate that diabetics are maintaining better control.

The emergence of pharmacy benefit management companies (PBMs) as major players in drug benefit design and pricing has generated criticism as well as praise. PBMs previously served as drug benefit administrators for employers and other payers. But as sponsors of Medicare Prescription Drug Plans (PDPs), they now assume risk and design coverage and payment options.

Recent data supports the success of Prescription Drug Plans (PDPs) under Part D.

Medication therapy management (MTM) has long been a part of the pharmacy lexicon and is based on the premise that the right medication in the right dose gets to the right patient. This is to ensure that optimal outcomes are achieved with the highest safety. Numerous examples of pharmacy programs in diverse settings utilize the skills of the pharmacist to optimize drug therapy and improve outcomes and assure safety. The Veterans Administration, academia, health plans, as well as community pharmacies have all been settings where medication management of the patient has occurred.

The deadline draws near for the healthcare industry to comply with one of the final regulations mandated by the Health Insurance Portability and Accountability Act (HIPAA) in the ongoing industrywide effort to get all arms on the same electronic page.

Washington, D.C.-The anticipated shakeout in Part D plans is not occurring this year. In fact, insurers and pharmacy benefit managers (PBMs) are offering more drug coverage options at lower costs for seniors.

National Reports-New Orleans officials recently announced that they believe the city has reached half of its previous population prior to Hurricane Katrina. Some of the city's hospitals have not reopened, and many doctors and allied health professionals have not returned to the city.

National Reports-New Orleans officials recently announced that they believe the city has reached half of its previous population prior to Hurricane Katrina. Some of the city's hospitals have not reopened, and many doctors and allied health professionals have not returned to the city.

Doctors' handwriting has always been a source of jokes, but it's not so funny when poorly written prescriptions lead to medication errors. Electronic prescriptions have the potential to save lives by negating errors in deciphering prescriptions and alerting physicians to adverse drug interactions before they write a prescription.

All health plans and providers that do business with Medicare, Medicaid and other federally sponsored health programs soon will have to adopt information technology standards and quality-measurement tools. The Medicare Modernization Act of 2003 (MMA) requires the Department of Health and Human Services (HHS) to establish standards for electronic prescription drug prescribing by 2008, and this policy is driving broader efforts to build health IT systems.

Winona Health, a locally owned and operated nonprofit organization in Winona, Minn., had an outdated and cumbersome technology infrastructure, which hampered its ability to serve its community. With more than 900 employees at Winona Health and its affiliates, Winona's financial and billing systems couldn't keep up with the firm's growth or increasingly complex reporting and tracking requirements. Of particular importance was automating Winona Health's human resources and payroll processes-employee hours were being logged manually, making the maintenance of labor law requirements for overtime, weekends and holidays time-intensive.

The healthcare industry, both nationally and globally, has just scratched the surface of possible uses for telemedicine with potential efficiency enhancements on the horizon as well as a future where homes would have "health security systems," according to some leaders in telemedicine.

As the nation faces a healthcare "affordability" crisis, market forces are driving changes such as consumer-directed healthcare, which is fueling the next revolution in healthcare: real-time transactions. At the center of this momentous change sits the health plan and its enterprise systems.

Healthcare consumerism is quite a paradox. Consumers are given more choices, but as options increase, so do risk, responsibility and confusion. There are many consumerism products available today; consumer-directed health plans (CDHPs) and healthcare savings accounts (HSAs) are two that are gaining momentum, but perhaps the most widely publicized is the government's prescription drug plan for seniors-Medicare Part D.

If you have not already added Medicare Advantage (MA) as part of your health plan's offerings, you are missing a key business opportunity. MA offers increased reimbursement, the chance to expand your product line, the ability to protect your senior business and a strategy for maintaining your membership base. It is worthwhile to recognize, though, that launching any new line of business always involves a certain amount of risk. The key to success is learning about and preparing for the opportunities and impacts of MA.

Medicare part D has put a new face on pharmaceutical benefits for seniors-even with all the glitches and challenges of implementing the largest social welfare program in 40 years. It welcomed 11.5 million Medicare beneficiaries prior to the May 15, 2006, deadline, according to final Medicare prescription drug benefit enrollment data.

Physicians insist that pay-for-performance programs should be voluntary and include risk-adjustments.

Healthcare consumerism is quite a paradox. Consumers are given more choices, but as options increase, so do risk, responsibility and confusion. There are many consumerism products available today; consumer-directed health plans (CDHPs) and healthcare savings accounts (HSAs) are two that are gaining momentum, but perhaps the most widely publicized is the government's prescription drug plan for seniors-Medicare Part D.

The rhetoric is heating up as health insurers and pharmacy benefit managers (PBMs) try to fend off an escalating attack from retail pharmacists about late or lost payments. Delayed payments are "simply profits these giant corporations will pocket," says National Community Pharmacists Assn. CEO Bruce Roberts. "The PBM industry adds no value to the healthcare delivery system."

In the past two years, not-for-profit hospitals have faced increasing scrutiny from a variety of sources. Lawsuits alleging unfair billing practices for the uninsured, congressional hearings regarding hospitals' tax-exempt status, federal and state legislative policies regulating hospitals' provision of charity care and front-page articles in major newspapers outlining overly aggressive efforts to collect payments from uninsured patients have all conspired to put this healthcare sector on red alert.

In a unanimous decision (Sereboff v. Mid-Atlantic Med. Svcs.) released on May 15, 2006, the U.S. Supreme Court permitted a health insurer to enforce a reimbursement provision against a participant. The plan had paid approximately $75,000 for the treatment of injuries suffered by the participant, Marlene Sereboff, and her spouse, who subsequently received $750,000 pursuant to a third-party tort settlement. The health plan provided that a participant who is injured by another person and receives benefits under the plan for such injuries must reimburse the plan from any amount recovered, without reduction, for failure to receive the full damages claimed. When the participant refused to comply with this reimbursement provision, the insurer obtained an injunction requiring the Sereboffs to set aside sufficient funds from the settlement, pending a final ruling in the case.

Widespread adoption of electronic medical record (EMR) systems in the future is a noble objective, however it has distracted policy makers from enabling true Health Information Technology (HIT) reform now. While others continue to champion EMR systems as former U.S. Department of Health and Human Services National HIT Coordinator David Brailer, MD, did, many in the health sphere confuse the advancement of EMRs with overall HIT reform. As industry pundits debate potential clinical benefits and cost reductions that EMR systems could deliver, there is too little discussion about how HIT can improve the single largest payer of medical claims-Medicaid.

Healthcare executives face an uphill struggle to reduce costs, grow revenues within a shifting payment landscape and ensure that patients receive quality, life-saving care. A tough assignment, especially when a critical shortage of workers sabotages those efforts.

With its first phase of certification rolling, the CertificationCommission for Healthcare Information Technology (CCHIT) willconcentrate on maintaining its momentum while moving to the realmof inpatient electronic health records (EHRs) in its secondcertification phase, followed by the evolving EHR networkinfrastructure in phase three.