Two key health reform bills in the House of Representatives and Senate include the option of a "public plan" as an additional source of health coverage. At least initially, the plan would primarily be structured to cover many of the uninsured and those who now have individual coverage. Because it is possible, and perhaps even likely, that this new public payer would pay less than private payers...

OBJECTIVE To review the impact of biologic therapies on commercial and government payers. SUMMARY Biologic agents, a mainstay in the treatment of cancer and immunopathologic conditions, are being used for an expanding number of indications, and new agents are being developed for use in many other diseases. These biologic agents have the potential to improve patient quality of life and the ove...

The authors of this paper use a case study approach to document and analyze the interactions that arise between two healthcare payers in Canada: the provincial public healthcare insurance plans and the provincial workers' compensation boards. Through a documentary review and semi-structured key-respondent interviews, the study identified a set of policy events and decisions undertaken by each p...

Medicare's prospective payment system (PPS) for hospital cases is based on diagnosis-related groups (DRGs). A wide variety of other third-party payers for hospital care have adapted elements of this system for their own use. The extent of DRG use varies considerably both by type of payer and by geographical area. Users include: 21 State Medicaid programs, 3 workers' compensation systems, the Ci...

Enteral nutrition (EN) is generally defined by third party payers as tube feeding for patients who cannot take food orally. EN is widely accepted in the United States as an effective, often life-sustaining therapy. Coverage and payment policies for EN differ among payers and settings. These differences often may depend on whether EN is reimbursed as a discrete therapy or subsumed into a larger ...

We aimed to assess the healthcare resource utilization (HCRU) and costs associated with atrial fibrillation (AF) examined disparities in rural settings. This was a retrospective cohort study. Data were collected from IBM MarketScan Research Databases 2015-2019. identified AF patients at least one inpatient diagnosis or two outpatient diagnoses non-AF without any diagnoses. Age, gender, health p...

Abstract Background One strategy to address the high number of U.S. opioid-related deaths is restrict high-risk or inappropriate opioid analgesic prescribing and dispensing. Federal state laws regulations have implemented restrictions but less known about commercial public payers’ policies aside from clinician anecdotal reports that these are increasing. To assess types with temporal trends, we...

Despite the pervasiveness of laboratory tests and their importance to medicine, evidence for their appropriate use often is very limited. In this article, we argue for a fundamental restructuring of the process by which laboratory tests are evaluated and reimbursed. We present an approach that would promote more evidence- based appraisals for laboratory tests. In addition, we urge that coverage...