Managed Care - March 2009 - (Page 2) EDITOR’S MEMO Care Editor M A N A G E D Million-Dollar Claims Challenge Plans’ Ingenuity By John Marcille JOHN MARCILLE Managing Editor FRANK DIAMOND Associate Editor E TONY BERBERABE Consulting Editor MICHAEL DALZELL Senior Contributing Editor MARGARETANN CROSS Contributing Editors LOLA BUTCHER JOHN CARROLL MAUREEN GLABMAN MARTIN SIPKOFF Design Director PHILIP DENLINGER President and Group Publisher TIMOTHY P. SEARCH, RPH President and Group Publisher TIMOTHY J. STEZZI Eastern Sales Manager SCOTT MACDONALD Senior Account Manager KENNETH D. WATKINS, III Director of Production Services ach month our Plan Watch column looks at some of the interesting things individual insurers are doing. This month we practically present an entire edition of Plan Watches. Our story on page 28 looks at how Harvard Pilgrim Health Care delivers such amazing HEDIS scores for cardiovascular care. Geisinger Health Plan comes front and center on page 36 as we look at how it dismisses the old notion of trying to control physicians with another approach that’s much less fractious and, it seems, much more effective. On page 40, Cigna unveils some of the findings from a study of 440,000 members that indicate that consumer-directed health plans foster better preventive medicine and save money to boot. I am not forgetting other health plans that are also praised for their efforts in this issue, but are sort of in the background. For instance, there is a very complimentary mention of Aetna in the Harvard Pilgrim story. Let us also not forget the official Plan Watch on page 44 in which Kaiser Permanente offers advice on how to keep physicians content. These are all great examples of how resourceful health plans can be, but they are not why you started reading this issue. No, it was probably because you got a gander at our cover about million-dollar claims. That story (page 14) by Contributing Editor Maureen Glabman highlights how plans with traditional levels of reinsurance can get into trouble, and describes other ways in which the megaclaim threat can be dealt with. The story of managed care is in many respects a story of how health insurers and integrated systems discover inadequacies in the system and create socially acceptable and effective ways of fixing them. It’s true that managed care has had limited success in controlling costs, and megaclaims are an extreme example, but I shudder to think where we would be, cost- and outcomes-wise, if we still had an uncontrolled indemnity system. MC WANETA PEART Circulation Manager CONTACT E-MAIL ADDRESSES: Editors: Editors_mail@ManagedCareMag.com Circulation: Managedcare@icnfull.com Advertising: Advertising_info@ManagedCareMag.com Reprints: Reprints_request@ManagedCareMag.com Clinical judgment must guide each clinician in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this publication may reflect the professional literature or other clinical sources, or may reflect the clinical experience of the authors, and might not be the same as what is on the approved package insert. Please consult the complete prescribing information for any products mentioned in this publication. MediMedia USA Inc. assumes no liability for the information published herein. MANAGED CARE (ISSN 1062-3388) is published monthly by MediMedia USA, Inc. at 780 Township Line Road, Yardley, PA 19067. This is Volume 18, Issue 3. Phone: (267) 685-2788; fax (267) 685-2966. Send letters to the editor to Frank Diamond, MANAGED CARE, 780 Township Line Road, Yardley, PA 19067. Letters may be edited for length and clarity. Copyright 2009 by MediMedia USA, Inc. All rights reserved under the United States, International, and Pan-American copyright conventions. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, electronic, or otherwise, without the prior written permission of MediMedia USA Inc. The copyright law of the United States governs the making of photocopies or other reproductions of copyrighted material. Subscriptions for individuals or institutions in the U.S.A. are $100 per year, $10 per single copy; elsewhere, $120 per year, $22 per single copy. Inquiries about paid subscriptions: Lisa Gardineer, telephone (267) 685-2789; e-mail: lgardineer@medimedia.com-. Postmaster: Send address changes to MANAGED CARE, PO Box 2019, Langhorne, PA 19067. Periodicals postage paid at Morrisville, PA, and at additional mailing offices. JACQUELYN OTT Major articles are reviewed by appropriate members of the editorial advisory board and/or other qualified experts. Opinions are those of the authors and not necessarily those of the institutions that employ the authors, nor of the publisher, editor, or editorial advisory board of MANAGED CARE. 2 MANAGED CARE / MARCH 2009
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.