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Changing Medication Use in Managed Care: A Critical Review of the Available Evidence (PDF)

17 pages. Excerpt: Objective: To review the effectiveness of strategies to improve the quality and efficiency of medication use in managed careorganizations (MCOs).

The Value Proposition in Healthcare (PDF)

2 pages. Excerpt: To engage our readers in lively discussion, The American Journal of Managed Care is inaugurating a series of editorials on value in healthcare. This month, Richard T. Clark, CEO of Merck & Co., provides his perspective. We invite you to share your thoughts with us about how value affects your industry, practice, and everyday lives.

Improve American Health Care by Moving Away from Employer-Sponsored Insurance

"Health care financed by insurance represents a major portion of the economy in America, and more than half of people with insurance are covered by their employer. For employers, approximately 30% of employee expenses go to benefits, of which health insurance is the largest component.... The major problem with this is that ESI leads to lower-quality, higher-cost health care while hurting the employer's productivity."

Impact of Two Employer-Sponsored Population Health Management Programs on Medical Care Cost and Utilization (PDF)

8 pages. Excerpt: Conclusions: Our results suggest that the programs did not reduce medical cost in their first year, despite a beneficial effect on hospital admissions. If we had been able to include program fees, it is likely that the overall cost would have increased significantly. Although this study had important limitations, the results suggest that a belief that these programs will save money may be too optimistic and better evaluation is needed.

The Value of Ambulatory Care Measures: A Review of Clinical and Financial Impact from an Employer/Payer Perspective (PDF)

9 pages. Excerpt: Given the current emphasis on pay-for-performance and pay-for-reporting programs, and recent studies showing a lack of relationship between measures and clinical/economic value, this analysis informs payers, purchasers, providers, and policymakers about the importance of choosing the right metrics and the methods for collecting them.

The Promise and Peril of Health Care Forecasting

"The growing use and increased sophistication of electronically mediated patient-level forecasting presents challenges for ethical use and opportunities for innovative applications. Health plans, method developers, and policy makers should adopt strategies that directly address these issues in order to maximize the benefit of healthcare forecasting on the longterm health of patients."

Report Shows Primary Care Doctors Have Limited Knowledge About Consumer-Driven Health Plans

Excerpt: A large proportion of the nation's primary care physicians are not prepared to advise patients enrolled in consumer-driven health plans on such issues as coverage limitations and cost considerations, a new survey has found. In fact, 43 percent of the doctors responding to the survey, which was conducted by the Robert Wood Johnson Foundation Clinical Scholars Program and published Wednesday, October 8, in the American Journal of Managed Care, said they have heard 'a little' or 'not at all' about consumer-driven health plans[.]

Legal Issues in Value-Based Care Contracts for Self-Insured Employers

"Implementing a value-based contract that ties payments to quality metrics or population health outcomes creates several fiduciary questions. Does shifting risk to a provider expose plan participants to narrower networks or limited access that may conflict with fiduciary obligations? How should fiduciaries evaluate whether the incentive structures truly benefit plan participants rather than merely reduce employer costs? ... Using standardized CMS data sets minimizes ambiguity and improves objective benchmarking. From a legal point of view, incorporating CMS data sets requires careful implementation. "

New Guideline Would Dramatically Increase Number of Americans with Hypertension

"The number of US adults who have high blood pressure could grow by as much as 31 million -- and the number of adults who will be recommended for antihypertensive treatment could increase by 11 million -- if full implementation of the American Heart Association's 2017 hypertension guideline is reached."

Trends in Hospital-Based Childbirth Care: The Role of Health Insurance

"US hospital-based births covered by private insurance were associated with higher rates of obstetric intervention than births paid for by Medicaid. After controlling for clinical, demographic, and hospital factors, cesarean delivery rates increased more rapidly among births covered by private insurance, compared with Medicaid. Changes in insurance coverage associated with healthcare reform may impact costs and quality of care for women giving birth in US hospitals."