Podcasts about Managed care

On this episode of Managed Care Cast, The American Journal of Managed Care® spoke with Jonathan Wrathall, PhD, a senior advanced analytics consultant at Elevance Health. He authored 2 studies published in the May 2026 issue, both of which centered on food insecurity: “Food Insecurity Identification Modeling for Medicare Enrollees Using Administrative Data” and “Making the Most of Limited Resources: Predicting Food Insecurity.” Throughout the conversation, Wrathall highlighted the motivation behind his studies, key food insecurity predictors, unexpected findings, and gaps in identifying needs across insurance groups. Before concluding, he rounded out the discussion by bringing the findings of both studies together to explain their implications for improving food insecurity detection in health systems.

Defining Clinical Utility in Managed Care On this episode guest host Steve Kheloussi, Principal Consultant with Kheloussi Consulting, sits down with Dr. John Fox, Senior Medical Director for the Americas at Illumina, to untangle the complexities of clinical utility. Drawing on his experience as a pediatrician and former health plan medical director, Dr. Fox explains why defining clinical utility remains a challenge for the industry and explores its critical role in precision medicine. From ending the "diagnostic odyssey" in pediatric rare diseases to the life-saving impact of large-panel biomarker testing in oncology, they discuss how the true value of a test lies in its power to change patient management and improve net health outcomes. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

Anjali Tiku Owens, MD - Contemporary Data, Differentiation, and Decision-Making in Hypertrophic Cardiomyopathy: A Guide to Cardiac Myosin Inhibition for the Managed Care Professional

Anjali Tiku Owens, MD - Contemporary Data, Differentiation, and Decision-Making in Hypertrophic Cardiomyopathy: A Guide to Cardiac Myosin Inhibition for the Managed Care Professional

Anjali Tiku Owens, MD - Contemporary Data, Differentiation, and Decision-Making in Hypertrophic Cardiomyopathy: A Guide to Cardiac Myosin Inhibition for the Managed Care Professional

Anjali Tiku Owens, MD - Contemporary Data, Differentiation, and Decision-Making in Hypertrophic Cardiomyopathy: A Guide to Cardiac Myosin Inhibition for the Managed Care Professional

Anjali Tiku Owens, MD - Contemporary Data, Differentiation, and Decision-Making in Hypertrophic Cardiomyopathy: A Guide to Cardiac Myosin Inhibition for the Managed Care Professional

Anjali Tiku Owens, MD - Contemporary Data, Differentiation, and Decision-Making in Hypertrophic Cardiomyopathy: A Guide to Cardiac Myosin Inhibition for the Managed Care Professional

Chronic kidney disease (CKD) affects an estimated 37 million Americans, yet most cases go undiagnosed until the disease has significantly progressed. A urine albumin-to-creatinine ratio (uACR) test can detect kidney damage years before a decline in the estimated glomerular filtration rate (eGFR), but it remains underutilized. In the first episode of Beyond the Silo: Integrated Care Across the CRM Continuum, a podcast series from The American Journal of Managed Care®, Marc P. Bonaca, MD, MPH, moderates a discussion with Josephine Harrington, MD, on why uACR has not yet become a standard of care, how CKD fits into the broader cardio-renal-metabolic (CRM) disease continuum, and what changes are needed across specialties, systems, and workflows. Bonaca is a cardiologist and vascular medicine specialist at the University of Colorado Anschutz and the executive director of CPC Clinical Research. Harrington is also a cardiologist, specializing in advanced heart failure and transplant cardiology at UCHealth's Heart and Vascular Center at the University of Colorado Hospital. Throughout the conversation, they emphasize that CKD is an early integral part of the CRM continuum, as it is both a driver and consequence of cardiovascular risk, with uACR elevation often appearing before eGFR decline and signaling increased risk even at mild levels. Despite strong guideline support, uACR screening remains underused due to structural barriers. Therefore, the experts explained that the primary barrier is not the test itself but the lack of streamlined workflows that make screening routine and results actionable without adding clinician burden. They concluded that early detection is critical because it enables the timely use of therapies such as SGLT2 inhibitors, glucagon-like peptide-1 receptor agonists, and finerenone, which improve outcomes. To close the gap, the experts noted that uACR should be treated as a routine vital sign for cardiometabolic risk and embedded into health system quality metrics to ensure consistent, accountable use.

Guest: Penny Lehoux, Manager of Managed Care at London Drugs Learn more about your ad choices. Visit megaphone.fm/adchoices

On this episode Kirollos Hanna, PharmD, Director of Pharmacy at Minnesota Oncology, discusses the rapidly shifting treatment landscape for chronic lymphocytic leukemia (CLL). The discussion covers the transition toward oral fixed-duration frontline regimens, the latest 2026 NCCN guidelines, and the emerging role of MRD testing. They also explore the clinical and economic implications of these therapies, including how the Inflation Reduction Act (IRA) is reshaping Medicare formulary strategies and patient access. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

Based on AHLA's annual Health Law Connections article, this special ten-part series brings together thought leaders from across the health law field to discuss the top ten issues of 2026. In the ninth episode, Kathy Roe, Managing Attorney, Health Law Consultancy, speaks with Judy Waltz, Partner, Foley & Lardner LLP, about the current areas of uncertainty surrounding Medicare Advantage (MA). They discuss why some MA Organizations (MAOs) are withdrawing plans, Humana v. Becerra and the potential impact on Risk Adjustment Data Validation audit processes and calculation of overpayment recoveries for MAOs, potential MAO network provider exposure under the False Claims Act, and what potential changes to MA might be on the horizon. From AHLA's Payers, Plans, and Managed Care and Regulation, Accreditation, and Payment Practice Groups.Watch this episode: https://www.youtube.com/watch?v=Az0cUVAjnFIRead AHLA's Top Ten 2026 article: https://www.americanhealthlaw.org/content-library/connections-magazine/article/a879dda5-35f9-46fb-ad45-1b0799343d74/Health-Law-Forecast-2026Access all episodes in AHLA's Top Ten 2026 podcast series: https://www.americanhealthlaw.org/education-events/speaking-of-health-law-podcasts/top-ten-issues-in-health-law-podcast-seriesLearn more about AHLA's Payers, Plans, and Managed Care Practice Group: https://www.americanhealthlaw.org/practice-groups/practice-groups/payers-plans-and-managed-care Learn more about AHLA's Regulation, Accreditation, and Payment Practice Group: https://www.americanhealthlaw.org/practice-groups/practice-groups/regulation-accreditation-and-payment Essential Legal Updates, Now in AudioAHLA's popular Health Law Daily email newsletter is now a daily podcast, exclusively for AHLA Comprehensive members. Get all your health law news from the major media outlets on this podcast! To subscribe and add this private podcast feed to your podcast app, go to americanhealthlaw.org/dailypodcast.Stay At the Forefront of Health Legal EducationLearn more about AHLA and the educational resources available to the health law community at https://www.americanhealthlaw.org/. 

In January, the CDC announced major revisions to the US childhood immunization schedule, reducing the number of diseases covered by routine vaccines from 17 to 11. The changes followed a December 2025 presidential memorandum directing HHS Secretary Robert F. Kennedy Jr and acting CDC director Jim O'Neill to update the schedule if “superior approaches” were identified abroad. The revisions also come months after Kennedy ended the terms of all 17 Advisory Committee on Immunization Practices members in June 2025 and quickly replaced them with new appointees, some of whom had previously expressed antivaccine views. He said the move was intended to restore public trust in vaccines. To better understand what these developments could mean for vaccine access and coverage, The American Journal of Managed Care® (AJMC®) spoke with Susan Cantrell, the CEO of the Academy of Managed Care Pharmacy, about the managed care pharmacy perspective on the updated recommendations. Throughout her conversation with AJMC, she discussed her reaction to the changes and their implications for pediatric vaccination and public health, as well as the evolving role of managed care pharmacists in supporting vaccine access and addressing vaccine hesitancy.

Managed Care Cast News Roundup: February 10, 2026 by Managed Care Cast

Feeling overwhelmed by Medicare choices? In this episode, we break down the critical differences between Managed Care (Medicare Advantage) and Patient Choice (Original Medicare + Medicare Supplement). Learn how provider networks, referrals, and prior authorizations can affect your access to care—and your freedom in retirement. Get the clarity you need to choose the coverage that truly fits your lifestyle. 

Join Kenny White, Alliant Healthcare, and Kathy Roe, Health Law Consultancy, as they examine recent federal and state developments shaping the regulation of artificial intelligence in healthcare and managed care, including a new executive order establishing federal priorities. Their discussion highlights state-level activity around prior authorization and mental health AI applications, alongside the growing tension between federal oversight and state enforcement. They also share practical considerations for organizations, from governance and risk management to compliance and insurance implications as AI adoption continues to evolve.

On this episode of Managed Care Cast, The American Journal of Managed Care® spoke with David Muhlstein, PhD, JD, founder and CEO of Simple Healthcare, about his recent articles highlighting Transparency in Coverage (TIC) files and ghost rates from 119 insurers, including 3 national commercial payers. Aetna, Cigna, and United Healthcare TIC files were more than 90% ghost rates—billing codes for procedures that would never be performed by a specific physician. For example, there were billing codes for heart surgery performed by a psychiatrist, Muhlstein said. These ghost rates increase the size of TIC files, making them difficult to evaluate for consumers, researchers, and analysts. Data files of this size muddle the true aim of the TIC files to provide actual transparency that would allow consumers to compare the prices of health care services and choose more affordable options.

MEDICARE ADVANTAGE MINUTE:                                                                  "WHAT IF WE COULD ELIMINATE PRIOR AUTHORIZATIONS?" Can we eliminate this scourge of Managed Care through increased use of computers? One exec thinks so! Someone discovered that about 40 million Americans use ChatGPT every day to ask questions about health concerns. Erica from Harmony Home Medical in San Diego might have been a wonderful guest but I was afraid the subject might be a little too depressing for my happy-go-lucky audience!                                                Contact me at: DBJ@MLMMailbag.com (Most severe critic: A+)                   Visit us on: BabyBoomer.ORG Inspired by: "MEDICARE FOR THE LAZY MAN 2026; SIMPLEST & EASIEST GUIDE EVER!" "MEDICARE DRUG PLANS: A SIMPLE D-I-Y GUIDE" "MEDICARE FOR THE LAZY MAN: ENROLLMENT GUIDE!" (coming soon) For sale on Amazon.com. After enjoying the books, please consider returning to leave a short customer review to  help future readers. Official website: https://www.MedicareForTheLazyMan.com.

The latest news from The American Journal of Managed Care.

To wrap up this year's author podcast series, The American Journal of Managed Care® speaks with Angela Liu, PhD, MPH, assistant research professor at the Johns Hopkins Bloomberg School of Public Health, about her December 2025 study, "Mental Health Care Use After Leaving Medicare Advantage for Traditional Medicare." Her research analyzed Medicare beneficiaries with mental health diagnoses who switched from Medicare Advantage (MA) to traditional Medicare (TM), examining their use of mental health services in the year before and after the switch. In this Managed Care Cast episode, Liu discusses what inspired her research, highlights the key findings, and explores ways to improve equitable access to mental health services for Medicare beneficiaries.

Send us a textAbout Dr. Joe Boorady:Joe Boorady, O.D., F.A.A.O. is a veteran in the eye care community with over 25 years of experience. He currently serves as Global CEO of Eureka Technology Holdings, LTD  and Euclid Systems Corporation.  Prior to Eureka, Dr. Boorady was the VP, Ocular Surface Disease at Johnson and Johnson Vision. Prior to Johnson and Johnson Vision he was the President and CEO of TearScience, Inc. which was acquired by Johnson and Johnson Vision in Sept. 2017. Before joining TearScience, Dr. Boorady was Senior Vice President of Sales, Service and Marketing at Zeiss Meditec, Inc. Dr. Boorady has spent over 25 years in the ophthalmic industry as an eye care professional, educational leader, entrepreneur and corporate executive. He has clinical experience as the founder and owner of several primary eye care practices in New York and New Jersey. He was the Vice President for Clinic Affairs and Executive Director of the University Optometric Center of the SUNY College of Optometry in New York City. Prior to his most recent position at SUNY, Dr. Boorady was Director of Continuing Professional Education, delivering eye care education to optometrists and ophthalmologists in over 20 countries, Director of Managed Care for eight years, Founding Director of the University Eye Care Network, IPA. Dr. Boorady has an O.D. from the SUNY-College of Optometry Class of 1993 and in 2010 he became an alumnus of the Harvard Business School.---If you're considering or have ever considered getting a virtual team member for your practice check out hiredteem.com, mention The Myopia Podcast when signing up for a $250 dollar discount off of your first month's teem member.https://hireteem.com/myopia-podcast/

It's In the News.. a look at the top headlines and stories in the diabetes community. This week's top stories: big FDA recall around Freestyle Libre (see more below to find out if you're affected), Dexcom launches their 15.5 day sensor, Omnipod announces enhancements, Tandem tests a fully closed loop (with high fat, high carb meals) and lots more! Find out how to submit your Community Commercial Find out more about Moms' Night Out  Please visit our Sponsors & Partners - they help make the show possible! Learn more about Gvoke Glucagon Gvoke HypoPen® (glucagon injection): Glucagon Injection For Very Low Blood Sugar (gvokeglucagon.com) Omnipod - Simplify Life Learn about Dexcom   Check out VIVI Cap to protect your insulin from extreme temperatures The best way to keep up with Stacey and the show is by signing up for our weekly newsletter: Sign up for our newsletter here Here's where to find us: Facebook (Group) Facebook (Page) Instagram Twitter Check out Stacey's books! Learn more about everything at our home page www.diabetes-connections.com  Reach out with questions or comments: info@diabetes-connections.com Episode transcription with links: Hello and welcome to Diabetes Connections In the News! I'm Stacey Simms and every other Friday I bring you a short episode with the top diabetes stories and headlines happening now. Our top story this week: XX Certain glucose monitors from Abbott Diabetes Care are providing users with incorrect glucose readings, an error that has been linked with the deaths of at least seven people and more than 700 serious injuries worldwide, according to an alert from the US Food and Drug Administration.   Incorrect glucose readings can lead to improper treatment. Abbott warned that about 3 million FreeStyle Libre 3 and FreeStyle Libre 3 Plus sensors are affected, but no other Libre products. Patients can visit FreeStyleCheck.com to see if their sensors are affected and to get a replacement for free.   The FDA has also published specific information about the affected products in its alert. The agency considers this to be a "potentially high-risk issue" and will continue to update its website as information becomes available.   "Patients should verify if their sensors are impacted and immediately discontinue use and dispose of the affected sensor(s)," the FDA said.   https://www.cnn.com/2025/12/02/health/abbott-diabetes-glucose-monitors https://www.freestylecheck.com/us-en/home.html XX Omnipod 5 is getting some enhancements.. and Omnipod 6 is announced. The FDA cleared updates including  a lower, 100 mg/dL target glucose option and what they call a more seamless automated experience. "This is the most significant algorithm advancement to our Omnipod 5 System since its launch in 2022," said Eric Benjamin, Insulet EVP and COO. Insulet said the new 100 mg/dL target glucose expands Omnipod 5's customization range. It now features six settings between 100 mg/dL and 150 mg/dL in 10 mg/dL increments. The company said this flexibility allows healthcare providers to tailor insulin delivery more precisely. It supports individuals seeking tighter glucose management or aiming to meet specific glucose goals. Omnipod 5's latest upgrades also help users stay in "Automated Mode" with fewer interruptions, even during prolonged high glucose events. Insulet plans to launch the updates to the algorithm in the first half of 2026. The company announced plans for an Omnipod 6 – without a lot of detail - at the company's Investor Day event in November. They also talked about a new, fully closed-loop pump for the type 2 diabetes population. https://www.drugdeliverybusiness.com/insulet-fda-clearance-omnipod-5-algorithm-enhancements/ XX Dexcom, the global leader in glucose biosensing, announced today that the Dexcom G7 15 Day Continuous Glucose Monitoring (CGM) System will launch in the United States on Dec. 1, making it the longest-lasting CGM system with 15.5 days of wear.   Dexcom G7 15 Day will first be available through durable medical equipment (DME) providers on Dec. 1 with full retail launch in the coming weeks. Dexcom G7 15 Day will also be covered for Medicare beneficiaries.   Dexcom G7 15 Day's industry-leading wear-time will provide fewer sensor changes, less disruption and more time for people with diabetes to benefit from life-changing CGM technology.   New with Dexcom G7 15 Day:  Longest lasting CGM system with 15.5 days of wear. Best-in-class accuracy1 with an overall MARD of 8.0%. Easier glucose management with fewer monthly sensor changes and reduced monthly waste. This follows yesterday's announcement – the FDA has cleared Dexcom Smart Basal, the first and only CGM-integrated basal insulin dosing optimizer designed for adults 18 and older with Type 2 diabetes using long-acting insulin. Dexcom Smart Basal will use Dexcom G7 15 Day sensor data and logged doses to calculate personalized daily recommendations to guide users towards a more effective long-acting insulin dose, as directed by their healthcare provider. At launch, Dexcom G7 15 Day will connect with the iLet Bionic Pancreas and Omnipod® 5§§. We are working closely with Tandem and look forward to extending the launch to their customers shortly as they finalize integration. For specific information on pump compatibility and availability with the Dexcom G7 15 Day system, visit Dexcom.com/connectedpumps https://investors.dexcom.com/news/news-details/2025/Dexcom-G7-15-Day-Continuous-Glucose-Monitoring-System-to-Launch-on-Dec--1-in-the-United-States/default.aspx   XX A small study of ten adults with type 1 diabetes tested Tandem's new fully closed-loop "Freedom" insulin system — and the participants put it through a real-world stress test. For 72 hours in a hotel setting, they ate heavy carb-and-fat meals, skipped all meal announcements, and didn't give any mealtime insulin boluses. The system handled almost everything automatically. Researchers said the device stayed in closed-loop mode 97% of the time and there were no incidents of diabetic ketoacidosis or severe hypoglycemia reported. While using the Freedom system, participants spent a median 61% of the day in the glucose target range — slightly higher than the 56% achieved with their usual pump at home. But the biggest improvement came overnight: time in range jumped to 96% with the closed-loop system compared to just under 70% during their home-pump week. With almost zero time spent below 70 mg/dL, researchers concluded that the fully automated Tandem system was both safe and effective even with unannounced, high-impact meals — hinting at a future of diabetes management that demands less effort from users.   XX Novo Nordisk reported promising mid-stage results for its experimental drug amycretin (AM-ee-creht-in) in diabetes patients on Tuesday. Amycretin, targets both GLP-1 and amylin hormones. In this study, it helped patients with type 2 diabetes lose up to 14.5% of their body weight over 36 weeks with weekly injections, far outperforming a placebo. The oral version delivered weight loss of up to 10.1%. Rival Eli Lilly  is surging ahead with its own amylin-based drug, eloralintide, which is advancing to late-stage testing after helping patients shed as much as 20% of their weight in a mid-stage trial. https://www.cnbc.com/2025/11/25/novos-next-gen-obesity-drug-shows-positive-results-heads-to-late-stage-testing.html XX The U.S. Medicare health plan said on Tuesday that newly negotiated prices for 15 of its costliest drugs will save 36% on those medications compared with recent annual spending, or about $8.5 billion in net covered prescription costs. The prices go into effect in 2027, including a monthly price of $274 for Novo Nordisk's popular GLP-1 drug semaglutide, sold as Wegovy for weight loss and Ozempic for diabetes. medicare's recent net price for Ozempic, opens new tab was $428 a month, according to an analysis published in the Journal of Managed Care and Specialty Pharmacy. Medicare put the drug's list price, before confidential rebates and discounts, at $959 a month. Based on such nondiscounted list prices, Medicare said savings on the 15 drugs ranged from 38% to 85%. The annual price negotiations were established under President Joe Biden's signature Inflation Reduction Act (IRA) of 2022. Previously, Medicare was barred by law from negotiating with drugmakers. https://www.reuters.com/business/healthcare-pharmaceuticals/us-negotiated-medicare-prices-15-more-drugs-test-cost-savings-promise-2025-11-25/   XX LifeScan announced its Chapter 11 bankruptcy reorganization plan received U.S. Bankruptcy Court approval. LifeScan said it's positioned to emerge from its financial restructuring process by the end of the year. The CEO says, "This balance sheet restructuring provides a stronger foundation for LifeScan to support our base business, advance new growth strategies, and commence our journey to become one of the most comprehensive players in the glucose management space." https://www.drugdeliverybusiness.com/glucose-monitor-lifescan-emerge-from-bankruptcy/ XX An artificial intelligence (AI)-led Diabetes Prevention Program (DPP) was as effective as a traditional human-led program in achieving recommended goals for weight loss, A1c reduction, and physical activity, according to a randomized trial of adults with prediabetes and overweight or obesity. One example of a push notification: "Looks like you're at the grocery store, Rita! Want a quick list of high-fiber snacks or smart swaps to stay on track this week?" The app also provided location- and goal-based education, with gamification elements to promote engagement. Approximately one third of participants in both the AI and human-led groups achieved the primary outcome (31.7% and 31.9%, respectively). Results were consistent across sensitivity analyses and individual components of the composite endpoint. "As more AI-based programs emerge, head-to-head comparisons among different AI-DPPs will be informative. An AI-led approach will not suit everyone; some individuals benefit more from human interaction and accountability," said Mathioudakis, adding that future research should focus on best matching patients to the modalities they prefer. https://www.medscape.com/viewarticle/ai-directed-diabetes-prevention-program-effective-human-2025a1000xam XX A new study suggets metformin could help people with type 1, reducing the need for insulin.  The researchers were surprised to find that metformin did not improve insulin resistance or change blood sugar levels. This suggests that, unlike in type 2 diabetes, metformin doesn't combat insulin resistance in type 1 diabetes.   However, metformin did reduce the amount of insulin people needed to keep their blood sugar levels stable.   https://www.the-express.com/news/health/192157/diabetes-medicine-insulin-type-1 XX Beyond Type 1 launches #TheBeyondType campaign in India to combat type 1 diabetes stigma. Nick Jonas is one of the founders of Beyond Type 1, his wife, Priyanka Chopra Jonas is his partner in this new non profit. The initiative highlights inspiring individuals living with T1D and partners with local organisations to improve awareness, medical support, and community networks for affected families across the nation. India has more young people living with T1D than any other nation, yet understanding of the condition remains limited. Beyond Type 1 is partnering with grassroots organisations across high-need regions. These include HRIDAY in Delhi–NCR, Nityaasha Foundation in Pune, Gram Jyoti in Jharkhand, and SAMATVAM Trust in Bangalore—each group focusing on improving awareness, providing medical support and building stronger community networks for young people with T1D.

In this episode, Tom Buckley shares the biggest revenue cycle challenges facing health systems today, from payer denials to rising patient financial responsibility, and how Virtua Health is using AI, automation, and strong communication practices to stay ahead. He also reflects on evolving leadership expectations and what it takes to keep teams resilient and aligned in a rapidly changing environment.

Today we are bringing you a conversation on the evolving landscape for idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) treatment. Ryan Haumschild, PharmD, MS, MBA, vice president of ambulatory pharmacy at Emory Healthcare and Winship Cancer Institute, spoke with Marilyn Glassberg, MD, the John W. Clarke Professor and Chair of medicine at Loyola University Chicago Stritch School of Medicine; Ayodeji Adegunsoye, MD, MSc, PhD, FACP, FCCP, assistant professor at the University of Chicago; and Janet Pope, MD, MPH, professor of medicine and division member of rheumatology at the University of Western Ontario in Canada. IPF and PPF are increasingly prevalent conditions that pose a growing burden on both patients and health care systems. Despite the availability of FDA-approved antifibrotic therapies, the median survival for patients with IPF and PPF remains less than 5 years after diagnosis—underscoring the critical unmet needs that persist in this field. The panelists discussed the impact these conditions have on patients' lives, evaluated emerging agents, and addressed economic considerations that affect treatment decisions and health care resource allocation.

In this episode of the NASP Podcast, Sheila Arquette, President & CEO of NASP, speaks with Matthew G. Bowles, PharmD, MBA, CSP, Pharmacy Clinical Team Lead with Vanderbilt Specialty Pharmacy, Vanderbilt Health, and lead author on the study “Getting to specialty treatment in dermatologic inflammatory conditions: Treatment requirements and patient journey,” published February 2025 in the Journal of Managed Care & Specialty Pharmacy. They discuss the reasons for conducting and results of the study, as well as the impacts the study may have on specialty and managed care pharmacy.

On this episode of Managed Care Cast, Rachel A. Prusynski, DPT, PhD, an assistant professor at the University of Washington's School of Medicine, speaks with The American Journal of Managed Care® about her research published in the November 2025 issue. Her study, "Medicare Advantage Reimbursement Structures Impact Home Health Delivery and Outcomes," explores how home health care delivery and patient outcomes differ between 3 plan types: traditional Medicare, episodic Medicare Advantage, and per-visit Medicare Advantage. Throughout the conversation, Prusynski discusses what motivated the research, the study's key findings, and the broader implications for improving the quality and accessibility of future home health care.

Nick Wood, speaking at the Kansas InterHab conference, discusses the role of InterHab as a statewide trade association supporting providers for people with intellectual and developmental disabilities (IDD). He emphasizes the benefits of collaboration, communication, and training among member organizations, as well as advocacy for policy improvements. Key challenges include workforce shortages, recruitment and retention of direct support professionals, and the need for person-centered approaches. Wood also explores the complexities of managed care in Kansas, highlighting its unique full-risk Medicaid model and the importance of integrating medical, behavioral, and long-term supports. He calls for better training, common language, and innovative solutions to address waiting lists and improve health equity for individuals with IDD.

CJ Dietzman and Tara Albin, Alliant Cyber, are joined by Kenny White, Alliant Healthcare, to examine the evolving role of artificial intelligence in the managed care industry. Their discussion explores how AI is streamlining administrative processes and compliance functions, while simultaneously introducing new exposures around privacy, vendor accountability and cyber risk. Together they highlight how proactive strategies such as implementing governance frameworks, employee training and AI literacy in an organization can strengthen resilience and manage risk in an increasingly automated environment.

         Medicare Advantage Minute:                                                                                Medicare users could soon lose perks they love, like choosing their own doctors!           Your Medicare Benefits 2025:                                                                            Shingles Shots We review recent rate increase filings in various states by various insurance companies. Is Medical inflation still with us or is it starting to subside? Contact me at: DBJ@MLMMailbag.com (Most severe critic: A+)                   Visit us on: BabyBoomer.ORG Inspired by: "MEDICARE FOR THE LAZY MAN 2025; SIMPLEST & EASIEST GUIDE EVER!" "MEDICARE DRUG PLANS: A SIMPLE D-I-Y GUIDE" "MEDICARE FOR THE LAZY MAN: BARE BONES!" For sale on Amazon.com. After enjoying the books, please consider returning to leave a short customer review to  help future readers. Official website: https://www.MedicareForTheLazyMan.com.

Today we are bringing you a conversation on how topical therapies can effectively manage atopic dermatitis. Brian Keegan, MD, PhD, FAAD, a dermatologist with Princeton Dermatology, spoke with Alexa Hetzel, MS, PA-C, physician assistant with Schweiger Dermatology Group; Vikash D. Oza, MD, director of pediatric dermatology at NYU Langone; and Amy Spizuoco, DO, FAOCD, dermatologist and dermatopathologist at True Dermatology. In addition to discussing the clinical benefits and impact on patient outcomes of using topical therapies for atopic dermatitis, the panelists explored how health economics research informs treatment decisions by demonstrating the cost-effectiveness and accessibility of topical therapies. The panel also analyzed the potential health care cost savings and resource optimization achieved through strategic use of topical treatments and atopic dermatitis management.

Research is more than just finding interesting stats. It's about finding better ways to deliver savings, simplicity, and support. In this episode, you'll hear from managed care pharmacy researchers who are doing just that, delivering data driven insights to drive affordability and access in health care.  Pat Gleason, PharmD, BCPS, FCCP, FAMCP, assistant vice president of health outcomes; Nick Friedlander, PharmD, clinical program pharmacist; and Simone Ndujiuba, PharmD, BCOP, clinical oncology pharmacist senior principal; and host Alex Cook, senior public relations manager, discuss how Prime's research helps address affordability and accessibility issues and guides health care providers and peers toward clarity on treatment for complex health conditions. Research topics covered:Three-Year Real-World Adherence and Persistence to Glucagon-Like Peptide-1 Receptor Agonists Among Commercially Insured Adults with Obesity without Diabetes Trends in Real-World Persistence to Weight Loss Glucagon-Like Peptide-1 Receptor Agonists from 2021 to 2024 Among Commercially Insured Adults without Diabetes — This study earned a platinum award from AMCP.  Impact of a Medical Claims Automated Glucagon Like Peptide-1 Drugs Prior Authorization Program— This study earned a gold award from AMCP.Validation of Long-term Savings from a Pharmacist-to-Prescriber Telephonic Intervention — This study earned a gold award from AMCP. Total Cost of Care and Adverse Effects Assessment of Bispecific T-cell Engagers and Chimeric Antigen Receptor T-cell Therapies for Relapsed Refractory Follicular Lymphoma  -------------------------Content in this podcast is for informational or educational purposes only.The content also does not substitute professional medical advice or consultations with health care professionals. Always seek advice from a physician or other health care providers with any questions you have regarding a medical treatment or condition before undertaking a new health care regimen.

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Melanie T. Turk, PhD, RN, an associate professor in the School of Nursing at Duquesne University and author of a study published in the October 2025 issue. Despite its potential, her study, "Opportunities and Obstacles Associated With the Medicare Diabetes Prevention Program," examines the challenges of implementing the Medicare Diabetes Prevention Program (MDPP) from the perspective of program suppliers nationwide. In this conversation, Turk discusses the limited adoption of the MDPP and the inspiration behind her study. She also outlines her key findings and shares next steps for implementing and sustaining the program.

On this episode of Managed Care Cast, The American Journal of Managed Care® spoke with Gen Li, PhD, CEO and cofounder of Phesi, a clinical data company that provides AI-driven insights to sponsors and providers to optimize clinical trial efficacy. A recent analysis from Phesi found over 100 diseases currently being studied using GLP-1 RA therapies. The rapid growth of GLP-1 RA therapies being used across multiple, overlapping conditions creates an incentive for efficient and easily accessible clinical trial data to aid sponsors and researchers in establishing control cohorts using Phesi's Trial Accelerator platform and digital patient profiles.

Navigating managed vision care can be complex.  Between reimbursements, benefits, and patient expectations, finding the balance between patient satisfaction and profitability is no small feat. But what if the key isn't fighting the system, but understanding lesser-known opportunities that exist within managed care?  In this episode of Power Hour, host Eugene Shatsman sits down with Todd Lassone, Senior Manager for Strategic Partners at EssilorLuxottica, to unpack how practices can optimize their relationship with managed vision care plans. With over 30 years of industry experience — both in the exam lane and on the corporate side — Todd brings a refreshingly practical perspective on turning managed care into managed opportunity. 

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Laxmi Patel, chief strategy officer at Savista, about how the proposed federal Budget Reconciliation Act could reshape Medicaid coverage nationwide. Patel explains why states with large immigrant populations, rural hospital dependence, or provider tax funding could face the most immediate disruptions and what payers can do to prepare. Building on AJMC's prior discussion with Patel on state-level Medicaid policy changes, this conversation explores how coverage loss, care deserts, and administrative burdens may evolve if these reforms move forward—and what proactive, state-specific strategies can help mitigate the impact.

A recent case filed by the U.S. Department of Justice (DOJ) reveals how an insider was able to detect fraud in a large managed care organization (MCO).Although the topic of medical loss ratio (MLR) might be arcane to some, when the subject involves millions of dollars of potential fraud, it quickly becomes a large blip on the government's fraud detection radar.More on this topic will be reported during the next live edition of Monitor Mondays. That's when whistleblower attorney Max Voldman returns to the long-running Internet broadcast to report on how a payer, Inland Empire Health Plan, miscalculated its MLR in a scheme to rebate less money to the government than to which it was legally obligated.The weekly broadcast will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.• Legislative Update: Cate Brantley, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

On this milestone episode of Unscripted, the AMCP Podcast, they celebrate the 30th anniversary of the Journal of Managed Care & Specialty Pharmacy (JMCP). Host Susan Cantrell, AMCP CEO, is joined by Laura Happe, PharmD, MPH, Editor-in-Chief of JMCP, and Pat Gleason, PharmD, BCPS, FCCP, FAMCP, Assistant Vice President, Health Outcomes at Prime Therapeutics to reflect on the journal's evolution from its 1995 launch to today's leading voice in managed care pharmacy. Highlights include JMCP's role in shaping policy, advancing research, and tackling pressing issues such as drug pricing, equity, and access—while looking ahead to the future of pharmacy innovation and collaboration. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

Still managing to add value for patients and payor While US markets make new highs, the S&P managed care index is half the level it was a year ago. We talk to Kevin Fischbeck about what's driven the substantial weakness and whether deterioration in medical loss ratios (MLR) is temporary or something that will last and prevent these companies from recapturing past margins. Kevin also discusses the different markets served by managed care, from commercial to Medicare Advantage to Medicaid and how profitability challenges are likely to last longer for some of these markets than for others. But he also addresses how managed care adds value to each of these settings, delivering care more effectively and cheaply than the alternatives. He notes that vertical integration is still part of the strategy at some managed care companies, and something that can still help to better align incentives, but that it's been overshadowed by challenges faced elsewhere in the business. You may also enjoy listening to the Merrill Perspectives podcast, featuring conversations on the big stories, news and trends affecting your everyday financial life.   "Bank of America" and “BofA Securities” are the marketing names for the global banking businesses and global markets businesses (which includes BofA Global Research) of Bank of America Corporation. Lending, derivatives, and other commercial banking activities are performed globally by banking affiliates of Bank of America Corporation, including Bank of America, N.A., Member FDIC. Securities, trading, research, strategic advisory, and other investment banking and markets activities are performed globally by affiliates of Bank of America Corporation, including, in the United States, BofA Securities, Inc. a registered broker-dealer and Member of FINRA and SIPC, and, in other jurisdictions, by locally registered entities. ©2025 Bank of America Corporation. All rights reserved.

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Richard A. Brook, MS, MBA, president of Better Health Worldwide, Inc., and author of a study published in the August 2025 issue. His retrospective analysis, "The Impact of Health Benefit Design on Patients With Infertility," examined how benefit design influences infertility treatment use and pregnancy outcomes. The study found that coverage for infertility treatment was associated with significantly higher use of assisted reproductive technology (ART) medications, more ART procedures performed, and improved pregnancy outcomes. In this conversation, Brook explores the current state of infertility care in the US, the inspiration behind his study, its key findings, and next steps to expand access to ART.

Breast cancer is the second most common cancer among women and the second leading cause of cancer-related deaths among women in the US. In light of Breast Cancer Research Awareness Day, the American Journal of Managed Care® breaks down the most recent advancements in breast cancer prevention, screening, and therapies.

Can food really be the prescription for better health? Discover how the “Food as Medicine” movement is reshaping health care and what it means for patients, providers, and the future of wellness. On this episode, special guests Noah Voreades of OLIPOP and Ivan Wasserman of Amin Wasserman Gurnani join Epstein Becker Green attorneys Jessika Tuazon and Ada Peters to explore how food is being integrated into health care to prevent and manage chronic diseases. The episode unpacks the policy priorities of Health and Human Services Secretary Robert F. Kennedy, Jr., the challenges of scaling food-based interventions, and the role of industry and government in driving innovation. Learn about the future of food as a clinical tool, the evolving regulatory landscape, and actionable takeaways for stakeholders navigating this transformative space. Visit our site for related resources and email contact information: https://www.ebglaw.com/dhc89. Subscribe for email notifications: https://www.ebglaw.com/subscribe. Visit: http://diagnosinghealthcare.com. This podcast is presented by Epstein Becker & Green, P.C. All rights are reserved. This audio recording includes information about legal issues and legal developments. Such materials are for informational purposes only and may not reflect the most current legal developments. These informational materials are not intended, and should not be taken, as legal advice on any particular set of facts or circumstances, and these materials are not a substitute for the advice of competent counsel. The content reflects the personal views and opinions of the participants. No attorney-client relationship has been created by this audio recording. This audio recording may be considered attorney advertising in some jurisdictions under the applicable law and ethical rules. The determination of the need for legal services and the choice of a lawyer are extremely important decisions and should not be based solely upon advertisements or self-proclaimed expertise. No representation is made that the quality of the legal services to be performed is greater than the quality of legal services performed by other lawyers.

Send us a textWhat happens when the demands of managed care clash with a provider's commitment to gold-standard hearing healthcare? For Jaysee Soto, owner of Altamonte Family Hearing in Florida, the answer lies in striking a delicate balance between business sustainability and patient-centered ethics.Growing up in his family's New York City bodega, Jaysee watched his parents build relationships with every customer who walked through their door. Those early lessons in community connection now form the foundation of his hearing healthcare practice, where patients aren't just customers, they're extended family. Working alongside his wife Grace, Jaysee has created a practice environment where comprehensive care is the standard, not the exception.The podcast takes us through Jaysee's unexpected journey from aspiring lawyer to passionate hearing care professional. That pivotal moment when he first witnessed a patient's face light up upon hearing their grandchild's voice clearly? It changed everything. Now he dedicates himself to creating those transformative moments for his patients, taking a full 90 minutes for comprehensive evaluations that far exceed industry minimums.But this level of care creates tension when insurance and managed care plans don't adequately compensate for best practices like real ear measurement and extensive testing. Jaysee candidly shares his approach to this industry-wide dilemma: strategically limiting managed care appointments while ensuring those patients still receive quality care, implementing service plans that bridge the gap, and planning for growth that maintains standards while increasing access.What emerges is a refreshing perspective on hearing healthcare economics. Rather than viewing patient care and business viability as opposing forces, he demonstrates how exceptional care creates its own sustainability through patient loyalty and word-of-mouth referrals. Even patients who initially come through managed care plans often return as private pay patients after experiencing the difference that comprehensive care makes.Ready to discover what ethical hearing healthcare looks like in action? Listen now and learn how leading with heart can transform both patient outcomes and practice success. Connect with the Hearing Matters Podcast TeamEmail: hearingmatterspodcast@gmail.com Instagram: @hearing_matters_podcast Twitter: @hearing_mattasFacebook: Hearing Matters Podcast

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Jonathan Gabison, MD, DABOM, and Stephen Lott, PharmD, MS. At the University of Michigan, Gabison is an obesity medicine specialist and family physician, while Lott serves as director of the postgraduate year one managed care residency program and manager of the university's prescription drug plan. Their qualitative study, "Understanding Insurance Coverage Policies for Incretin Mimetics for Weight Management," determined that the high costs associated with these therapies limit insurance coverage and contribute to variation in utilization management strategies aimed at controlling short-term spending. During the conversation, the investigators discuss how high costs, misconceptions about obesity, and inconsistent coverage policies continue to hinder equitable, patient-centered care.

Kenny White and Fred Driscoll, Alliant Healthcare, is joined by Seth Madnick, Alliant Captives, to examine how captive insurance continues to shape risk financing strategies in the managed care and ancillary healthcare sectors. The team outlines key considerations for feasibility, formation and utilization, highlighting benefits such as control over coverage terms, cost efficiency and streamlined access to reinsurance markets.

Managed Care Cast News Roundup: July 8, 2025 by Managed Care Cast

This episode recorded live at the Becker's 3rd Annual Spring Payer Issues Roundtable features Dr. Brian Smolich, Vice President, Health Alliance Quality and Managed Care Operations, Carle Health. Dr. Smolich shares how his organization is balancing cost and quality, leveraging biosimilars, digital engagement tools, and provider collaboration to improve member outcomes and transform the care experience.

On this episode host Fred Goldstein invites Joe Honcz, from C4I consulting and an AMCP Board Member to discuss AI and its potential uses in Managed Care Pharmacy. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

A quick roundup episode of major news and health policy developments from The American Journal of Managed Care.

On this episode of Managed Care Cast, The American Journal of Managed Care® speaks with Julia Lucaci, PharmD, MS, the senior director of global health economics and outcomes research at Becton, Dickinson and Company (BD), an international medical technology company. Her commentary, "Should Payers Incentivize Pharmacies to Blister-Package Chronic Medications?" argues that payers should consider offering higher reimbursement rates and/or preferred network status to pharmacies that dispense chronic medications in blister packs to enhance medication adherence and patient outcomes. During the conversation, Lucaci explores the widespread impact of medication nonadherence, the benefits and underutilization of blister packaging in the US, and strategies that could support broader adoption to improve chronic disease management and lower overall health care costs.

While tariffs continue to dominate headlines, our Global Head of Fixed Income Research and Public Policy Strategy Michael Zezas suggests investors should also focus on the sectoral impacts of additional U.S. policy choices.----- Transcript -----Welcome to Thoughts on the Market. I'm Michael Zezas, Morgan Stanley's Global Head of Fixed Income Research and Public Policy Strategy. Today, we'll be talking about U.S. policy impacts on the market that aren't about tariffs.It's Wednesday, March 12th, at 10:30am in New York.If tariffs are dominating your attention, we sympathize. Again this week we heard the U.S. commit to raising tariffs and work out a resolution, this time all within the span of a workday. These twists and turns in the tariff path are likely to continue, but in the meantime it might make sense for investors to take some time to look away – instead focusing on some key sectoral impacts of U.S. policy choices that our Research colleagues have called out. For example, Andrew Percoco, who leads our Clean Energy Equity Research team, calls out that clean Energy stocks may be pricing in too high a probability of an Inflation Reduction Act (IRA) repeal. He cites a letter signed by 18 Republicans urging the speaker of the house to protect some of the energy tax credits in the IRA. That's a good call out, in our view. Republicans' slim majority means only a handful need to oppose a legislative action in order to block its enactment. Another example is around Managed Care companies. Erin Wright, who leads our Healthcare Services Research Effort, analyzed the impact to companies of cuts to the Medicaid program and found the impact to their sector's bottom line to be manageable. So, keeping an in-line view for the sector. We think the sector won't ultimately face this risk, as, like with the IRA, we do not expect there to be sufficient Republican votes to enact the cuts. Finally, Patrick Wood, who leads the Medtech team, caught up with a former FDA director to talk about how staffing cuts might affect the industry. In short, expect delays in approvals of new medical technologies. In particular, it seems the risk is most acute in the most cutting edge technologies, where skilled FDA staff are hard to find. Neurology and brain/computer interfaces stand out as areas of development that might slow in this market sector. All that said, if you just can't turn away from tariffs, we reiterate our guidance here: Tariffs are likely going up, even if the precise path is uncertain. And whether or not you're constructive on the goals the administration is attempting to achieve, the path to achieving them carries costs and execution risk. Our U.S. economics team's recent downgrade of the U.S. growth outlook for this and next year exemplifies this. Thanks for listening. If you enjoy the show, please leave us a review wherever you listen and share Thoughts on the Market with a friend or colleague today.