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Episode 9 - Benefit Design and Making Treatment Affordable
Dr Dunn introduces the discussion of benefit design, suggesting that managed care providers may be unprepared to administer specialty drugs. He explains that specialty medications’ tiered system often does not incentivize providers to use less expensive medications. He suggests that stakeholders should reassess misaligned incentives in benefit design, especially for treatment options such as biosimilars.
Dr Quinn says that sometimes providers, including those like himself, are often unaware of the alternative options to newer, costlier drugs. Generics may be one way to offer providers and patients more cost-effective options for treating prostate cancer.
“It’s going to change, I think, our treatment,” Dr Quinn says. He adds that active management tools can help providers and patients understand the value of therapy options that provide equal benefits to costlier drugs, but for less out-of-pocket costs.
New Research Challenges Assumptions About Hospital-Physician Integration, Medicare Patient Mix
April 22nd 2025On this episode of Managed Care Cast, Brady Post, PhD, lead author of a study published in the April 2025 issue of The American Journal of Managed Care®, challenges the claim that hospital-employed physicians serve a more complex patient mix.
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ACOs’ Focus on Rooting Out Fraud Aligns With CMS Vision Under Oz
April 23rd 2025Accountable care organizations (ACOs) are increasingly playing the role of data sleuths as they identify and report trends of anomalous billing in hopes of salvaging their shared savings. This mission dovetails with that of CMS, which under the new administration plans to prioritize rooting out fraud, waste, and abuse.
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Personalized Care Key as Tirzepatide Use Expands Rapidly
April 15th 2025Using commercial insurance claims data and the US launch of tirzepatide as their dividing point, John Ostrominski, MD, Harvard Medical School, and his team studied trends in the use of both glucose-lowering and weight-lowering medications, comparing outcomes between adults with and without type 2 diabetes.
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Contributor: For Complex Cases, Continuity in Acute Care Is Necessary
April 23rd 2025For patients with complex needs and social challenges like unstable housing, the hospital has become their de facto medical home—yet each visit is a fragmented restart, without continuity, context, or a clear path forward.
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