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The Services provided by PPO plans are influenced by a number of factors, say industry watchers.

Winona Health, a locally owned and operated nonprofit organization in Winona, Minn., had an outdated and cumbersome technology infrastructure, which hampered its ability to serve its community.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.

With radiology costs in the United States growing to more than $100 billion annually, diagnostic imaging is the second-largest and fastest-growing expense for health plans behind pharmaceuticals. Unmanaged, radiology spending is expected to continue growing at a rate of 20% annually. Factors driving this growth include fragmentation of care, the continual advances in diagnostic imaging technology, the affordability of imaging equipment leading to adoption and utilization in more care settings, direct advertising to patients, and an aging population. As a result, radiology utilization management has become a top priority for health plans.

Telemedicine programs decrease time-to-diagnosis, save financial resources and reduce hospital stays.

One of the things I love about living in the suburbs is the close proximity of retail when I need to get my errands done. In a three-mile stretch, I can eat lunch, hit the ATM, buy a gift, fill up my gas tank and replenish my groceries. At the grocery store, I can buy stamps and drop off my dry cleaning, too.

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.

As the healthcare industry strives to establish appropriate and effective standards for the public reporting of clinical data, providers may lose sight of how they can make a critical difference in ensuring new reporting standards do not distract from, but rather aid in, achieving the primary goal of improving patient care.

New incretin-based therapies will soon enter the therapeutic armamentarium for type 2 diabetes. Two dipeptidyl peptidase (DPP)-IV inhibitors in phase 3 clinical trials, vildagliptin and sitagliptin, are oral agents that can be used once daily as monotherapy or in combination with other oral antidiabetic agents to reduce levels of hemoglobin A1c (HbA1c) with few side effects, little risk of hypoglycemia, and no promotion of weight gain, researchers reported at the 66th scientific sessions of the American Diabetes Association (ADA) in Washington, DC.

Anidulafungin (Eraxis, Pfizer) is a new echinocandin approved for the treatment of Candida infection in adults. Like other echinocandins, anidulafungin acts on the fungal cell wall by inhibiting 1,3 beta-D glucan synthesis. Studies suggest that among the echinocandins, anidulafungin may have more potent in vitro activity against Candida spp and Aspergillus spp. Further, phase 2 and 3 clinical studies with anidulafungin have supported a high end of therapy success rates for invasive candidiasis, including esophageal candidiasis. Anidulafungin appears to be well tolerated, with headache, nausea, vomiting, phlebitis, neutropenia, and hypokalemia being the most commonly reported adverse effects. Importantly, as anidulafungin is chemically degraded, it has no clinically significant drug interactions and does not require any dose adjustment for renal or hepatic impairment.

The role of cost- and pharmacoeconomic-related criteria in formulary decision-making was assessed in a literature review of 31 studies of hospital (n=18) and managed care (n=13) pharmacy and therapeutics (P&T) committees. In both settings, cost was important, although the elements of cost considered varied. Acquisition cost was mentioned more frequently than pharmacoeconomic or cost-effectiveness information. Other factors, including drug characteristics, quality of life, supply-related issues, and physician demand, also influenced decisions.

Metronidazole topical gel, 0.75% (equiv to Metrogel topical gel)

Hepatitis B immune globulin (human) (Nabi-HB, Nabi Bio-pharmaceuticals) for the treatment of hepatitis B infection

FDA approved the etonogestrel 68-mg implant (Implanon, Organon), a single-rod implantable device that prevents pregnancy for up to 3 years.

This fixed-dose combination tablet contains: efavirenz, a non-nucleoside reverse transcriptase inhibitor (NNRTI); emtricitabine, a synthetic nucleoside analog of cytidine; and tenofovir disoproxil, which is converted in vivo to tenofovir, an acyclic nucleoside phosphonate (nucleotide) analog of adenosine 5'-monophosphate.

Dasatinib is an inhibitor of multiple tyrosine kinases and is active in vitro against leukemic cell lines representing variants of imatinib-sensitive and -resistant disease.

This inhibitor of human immunodeficiency virus type 1 (HIV-1) protease selectively inhibits the cleavage of HIV-encoded Gag-Pol polyproteins in infected cells, thereby preventing the formation of mature virus particles.

This recombinant humanized IgG1 monoclonal antibody fragment binds to the receptor-binding site of active forms of human vascular endothelial growth factor A (VEGF-A).

A review of agents in late-stage development for the treatment of generalized anxiety disorder and sleep disorders (August 2006).

An ongoing issue among insurers is how to determine "usual and customary" (U&C) charges for medically necessary services that are provided by out-of-network providers. While some state laws require an insurer to pay U&C charges, there often is limited guidance as to how to calculate those charges. Case law from various jurisdictions, as well as several treatises, suggest that U&C may be based on the prevailing rates for similar services in the community and that actual charges billed by the provider are not determinative.

Every year, the poor quality of provider data costs healthcare payers an estimated $26 billion and sabotages their quest for efficient operations. Even the most highly automated plans remain vulnerable to the drain on resources caused by inaccurate provider data, rightly called "the Achilles' heel" of healthcare.

The aging baby-boomer population most likely is driving the health consumerism trend. Baby boomers now have more disposable income than any similar age group in the history of the United States. Now, as patients or care-providers for children and elderly patients, baby boomers are visiting physician offices armed with more information about medical conditions, but also are dissatisfied with the "interruption" to their lives caused by long waits in doctors' offices. They also are more interested in managing their own health and are investing heavily in health management aids including health club memberships, vitamins, herbal medicines, fad diets-virtually anything that will prolong or provide a healthier life.

Since the new San Francisco Health Access plan, approved in July, only covers preventive and catastrophic care, everyone who will receive coverage still needs to learn how to become an astute buyer, according to Chini Krishnan, founder and CEO of Healthia Inc., an integrated comparison-shopping portal for healthcare products and services, headquartered in Mountain View, Calif.

The top five HMO enrollment states also have high immigrant populations, says Cynthia Marcotte Stamer, a member of Glast, Phillips & Murray, PC, Dallas, Texas. "Among the top 20 HMO enrollment states, California, New York, Texas and Florida also are on the list of states qualifying for special Emergency Medical Treatment and Active Labor Act (EMTALA) Medicare reimbursements for undocumented aliens under MMA Section 1028."

The educational and professional qualifications of health coaches is relative to the type of health coaching that is being done, according to industry experts.

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.

There's no doubt that HMO enrollment has been declining in recent years, experts say. Various factors explain this enrollment decline.

The issues have been framed brilliantly, debated enthusiastically and examined closely. While it might not resemble the California Gold Rush, employers that implement wellness programs can still find significant rewards.