The common law power of the legislature: insurer conversions and charitable funds.
(17/75)
New York's Empire Blue Cross and Blue Shield conversion from nonprofit to for-profit form has considerable legal significance. Three aspects of the conversion make the case unique: the role of the state legislature in directing the disposition of the conversion assets, the fact that it made itself the primary beneficiary of those assets, and the actions of the state attorney general defending the state rather than the public interest in the charitable assets. Drawing on several centuries of common law rejecting the legislative power to direct the disposition of charitable funds, this article argues that the legislature lacked power to control the conversion and direct the disposition of its proceeds and that its actions not only undermined the nonprofit form but also raised constitutional concerns. (+info)
Variability and growth in spending for outpatient specialty pharmaceuticals.
(18/75)
Specialty pharmaceuticals are a unique group of drug agents used to treat complex clinical conditions. Many specialty pharmaceuticals are biological in nature and administered through injection or infusion. Tracking spending on these pharmaceuticals is complex, because these products may be processed as either medical or pharmacy claims. This benchmarking study of ten Blue Cross Blue Shield plans, representing almost eighteen million covered lives, documents large expenditures on select specialty pharmaceutical categories and much variation in spending across plans, age groups, and time. Our results underscore the need for insurers to scrutinize trends in specialty pharmaceutical spending and identify appropriate management strategies. (+info)
The best of times and the worst of times: A conversation with Vicky Gregg. Interview by James C Robinson.
(19/75)
Blue Cross and Blue Shield plans have enjoyed enviable financial success, while much of the health care delivery system has faced severe financial strains. The contrast is striking in Tennessee, where BlueCross BlueShield of Tennessee dominates the commercial health insurance market and administers much of the state's Medicaid program, TennCare, while TennCare itself recently dropped hundreds of thousands of enrollees from coverage because of budgetary constraints. CEO Vicky Gregg draws lessons from the TennCare crisis for other states; describes her organization's investment in information technology, pricing policies, and management of new clinical technologies; and explains the continued political popularity of a profitable nonprofit health plan. (+info)
Health plans respond to parity: managing behavioral health care in the Federal Employees Health Benefits Program.
(20/75)
The government often uses the Federal Employees Health Benefits (FEHB) Program as a model for both public and private health policy choices. In 2001, the U.S. Office of Personnel Management (OPM) implemented full parity, requiring that FEHB carriers offer mental health and substance abuse benefits equal to general medical benefits. OPM instructed carriers to alter their benefit design but permitted them to determine whether they would manage care and what structures or processes they would use. This article reports on the experience of 156 carriers and the government-wide BlueCross and BlueShield Service Benefit Plan. Carriers dropped cost-restraining benefit limits. A smaller percentage also changed the management of the benefit, but these changes affected the care of many enrollees, making the overall parity effect noteworthy. (+info)
Health plans' strategies for managing outpatient specialty pharmaceuticals.
(21/75)
Balancing increased spending for specialty pharmaceuticals while providing affordable and equitable coverage for consumers is a key issue for public and private payers. Health plans rely on an array of strategies, including both medical management and those used for more traditional pharmaceuticals. To explore specific management strategies for outpatient specialty pharmaceuticals, a survey was administered to thirty-eight Blue Cross and Blue Shield plans, focused on identifying core strategies. Prior authorization was the most commonly used strategy, implemented by 83.3 percent of respondents. Other frequently implemented management strategies included claims review (82.8 percent), formulary management (76.7 percent), and utilization review (70 percent). (+info)
Managing biotechnology in a network-model health plan: a U.S. private payer perspective.
(22/75)
Emerging biotechnology poses challenges to payers, including access, coverage, reimbursement, patient selection, and affordability. Premera Blue Cross, a private regional health plan, developed an integrated cross-functional approach to managing biologics, built around a robust formulary process that is fast, flexible, fair, and transparent to stakeholders. Results are monitored by cost and use reporting from merged pharmacy and medical claims. Utilization management and case management strategies will integrate with specialty pharmacy programs to improve outcomes and cost-effectiveness. Creative approaches to provider reimbursement can align providers' incentives with those of the plan. Redesign of member benefits can also encourage appropriate use of biotechnology. (+info)
Brief report: development of a prescription medication information webliography for consumers.
(23/75)
BACKGROUND: Websites offering drug information vary in coverage and quality, and most health care consumers are poorly equipped to assess the quality of internet medication information. OBJECTIVE: To establish a webliography of recommended prescription medication information websites for health care consumers and providers. DESIGN AND METHODS: Drug information websites were systematically identified based on recommendations from health professionals and text-word searches of MEDLINE and Google. The resulting sample of websites was evaluated in a 2-step process. Candidate websites were first screened using inclusion/exclusion criteria representing minimum information requirements. Websites that passed the inclusion/exclusion criteria were then rated on 16 quality criteria using a 5-point scale by 3 trained judges. Website ratings were averaged, then multiplied by the corresponding importance weight of each criterion and summed to generate a total score. Websites with the highest total scores were included in the webliography. RESULTS: Ten websites were selected for inclusion in the webliography. The 3 highest-scoring websites were Anthem Blue Cross and Blue Shield (http://home.anthemhealth.com/topic/drugcenter), U.S. National Library of Medicine (http://www.nlm.nih.gov/medlineplus/druginformation.html), and Healthvision (http://www.yourhealthinformation.com/library/healthguide/en-us/drugguide/default .htm). CONCLUSION: Medication information websites vary widely in quality and content. The online webliography is a valuable and easily accessed tool that can be recommended by health care professionals to patients who request referral to reliable websites. (+info)
Improving tomorrow's health care with today's tools: a conversation with Larry C. Glasscock. Interview by John K. Iglehart.
(24/75)
The chairman and CEO of WellPoint Inc. provides some factual background on one of the nation's largest health insurers, which covers 34.2 million lives. Its own employees are offered the opportunity to join a consumer-directed health plan, which gives the company some real-life data on which to base its strategies in the marketplace. Glasscock believes that future reform efforts in his company and at the national level must focus on improving quality and affordability, reducing the number of uninsured Americans, and improving the health of those insured by WellPoint and everyone else. (+info)