For payers struggling with unmanageable cost increases in the business of delivering care, however, price cannot be overlooked. Insurers don't necessarily deny coverage of a treatment just because it's expensive, but they would be remiss if they didn't take cost into consideration, as well as safety and effectiveness.
As durable medical equipment (dme) becomes increasingly sophisticated, MCOs' challenges remain rooted in establishing medical necessity. To that end, most use strategies including prior authorization and coverage limits. Meanwhile, they must also satisfy changing state and national regulatory requirements.
IN THE WORLD OF professional sports, the competition isn't only on the gridiron, the court or the diamond. Just ask an MCO.
The economics and the politics behind the major healthcare problems affecting men, such as cardiovascular disease, cancer, obesity and depression, aren't receiving the attention they deserve. It has been the rule that women make health decisions for themselves and also for their male partners and their children. In contrast, most men have a more casual attitude toward their care: "if it ain't broke, don't fix it."
Grace seems an unlikely acronym for a study of acute coronary events, but given the findings of the Global Registry of Acute Coronary Events published in the Journal of the American Medical Association, the name may be apropos.
Worldwide, 388 million people will die from chronic diseases in the next 10 years. Chronic diseases account for about 75% of all healthcare costs. Clearly, disease management and prevention is sorely needed, but it's been a struggle to change the behaviors of large groups of people. A number of programs are finding success using non-traditional methods.
Disease management as we now define it may be on its last legs, though no one knows it yet. The Disease Management Purchasing Consortium has noticed that the savings in all but a few diseases doesn't offset the costs, and nowhere does it generate the level of return on investment (ROI) that some people think they are getting.
The centers for Medicare and Medicaid (CMS) says that 23% of Medicare beneficiaries have five or more chronic conditions but account for 68% of costs—not quite the 80/20 rule. And they tend to see many different doctors—about 14 a year with almost 40 office visits—and take as many as 10 medications at a time, according to Partnership for Solutions.