July/August 2010, Vol 3, No 4

Under the Patient Protection and Affordable Care Act (PPACA) of 2010, Medicare providers, including physician groups and hospitals, will soon have the option to form accountable care organizations (ACOs) to improve quality and efficiency. ACO participants may share financial gains generated from improved clinical and economic performance, provided that quality goals and patient safeguards are met.

The accountable care organization (ACO) model is a new Medicare option for physicians, hospitals, and other providers to share in cost-savings. ACOs represent a dramatic change in Medicare policy and an opportunity to transform care delivery and provider alignment.

The Healthcare Reform Act—officially called the Patient Protection and Affordable Care Act (PPACA)—institutes sweeping changes across all healthcare stakeholders, including payers, providers, and plan members. In fact, the amount of change required by the PPACA is so extensive, distilling all the changes down and accounting for their impact is a serious challenge for the industry as a whole.

A report prepared by IMS Health for the Generic Pharmaceutical Association (GPhA) and released in July 2010 shows that the utilization of generics substituted for brand-name products has been making great leaps since 2006.1 The report spans the decade from 2000 through 2009, comparing the rate of generic utilization in each of the past 10 years, and highlighting the exponential rate increase in the past 4 years (Table 1).1

Much attention is now focused on bundled payment as a promising mechanism of healthcare reform.

We economists always think that waving money under people’s noses will make them behave according to some theoretical script. But we’ve tried that with healthcare for decades and it hasn’t worked. Healthcare isn’t just about financial incentives; it’s also about anxiety, fear, habit, guan-xi—a Chinese word that, loosely translated, means “family or business ties”—and professional pride.

Anti-tumor necrosis factor (TNF) therapy has emerged as a major advancement in the management of rheumatoid arthritis (RA). The anti-TNF agents adalimumab, etanercept, and infliximab are often used with conventional disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, and have been shown in clinical trials to be effective in reducing the signs and symptoms of RA and in preventing the progression of joint damage.1-6

Effectiveness of Anti-TNFs in Patients with RA, and Coverage Considerations

Breast cancer is the most frequently diagnosed cancer in US women, and ranks second among cancer- related deaths in women, after lung cancer.1 It is estimated that $8.1 billion (in 2004 $US) in total healthcare costs are spent annually on breast cancer diagnosis and treatment in the United States.2 Chemotherapeutic agents represent a significant portion of the cost of breast cancer treatment, and health plans are managing these costs with care pathways and other utilization management strategies.

Can We Afford Improved Clinical Outcomes?

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  •  Association for Value-Based Cancer Care
  • Oncology Practice Management
  • Value-Based Cancer Care
  • Value-Based Care in Rheumatology
  • Rheumatology Practice Management
  • Urology Practice Management
  • Lynx CME