John Jesitus

He is a frequent contributor to Managed Healthcare Executive. He is based in Colorado.

Many organizations believe a free-market system is the best approach to healthcare, but the free market struggles against lagging public policy. Especially as consumers are demanding greater control, advocates point to other industries in which competition has driven down prices and inspired higher quality.

Denver—A UnitedHealthcare initiative underway in Colorado and a handful of other states allows high-deductible PPO plan members to cut their deductibles as much as $4,000 by meeting certain wellness benchmarks. Called Vital Measures, the program launched June 1 in Colorado, Pennsylvania, Ohio and Rhode Island, and is drawing employer interest, says Cheryl Randolph, UnitedHealthcare spokesperson.

As durable medical equipment (dme) becomes increasingly sophisticated, MCOs' challenges remain rooted in establishing medical necessity. To that end, most use strategies including prior authorization and coverage limits. Meanwhile, they must also satisfy changing state and national regulatory requirements.

THE ADVENT OF COSTLY biologic drugs for psoriasis hasn't inspired the inappropriate prescriptions many MCOs expected. But that's largely because MCOs are employing a firm hand in managing these drugs early on, educating providers and patients before new drugs come to market and implementing prior authorization (PA) requirements that balance patient access with cost effectiveness. While some policies occasionally require tweaking, sources agree that physicians are not taking these prescriptions lightly.

Denver - Under state law, patients who believe physicians have been negligent have been unable to sue the corporate entities that employ them, except in very limited circumstances. That could change, however, as the result of a recent Colorado Supreme Court decision.