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The drug has to be on what is called "the formulary," a list that managed care groups approve.
The managed care groups that withdraw such coverage now are prohibited from returning to a market for two years.
All medical imaging companies are facing squeezed margins, as hospitals and managed care groups band together into huge purchasing cooperatives to force prices down.
The situation is complicated by time constraints on doctors who are part of managed care groups, said Prof. E. Haavi Morreim, an ethicist at the University of Tennessee College of Medicine.
The case has been closely watched by state medical officials and physicians' groups as states have increasingly tried to make medical directors at health maintenance organizations and other managed care groups subject to the same licensing and disciplinary oversight as other doctors.
With backing from Consumers Union, AARP, managed care groups and many others, Senator Hillary Rodham Clinton, Democrat of New York, successfully pushed for a provision in the fall Medicare bill providing $50 million for head-to-head trials of comparable drugs.
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The difference in the variation for the managed and non-managed care groups at hospital level and at physician level is measured as a ratio (the variation of the managed care group divided by the variation of the non-managed care group).
These results do not provide unequivocal evidence indicating that the variation within the managed care group is smaller than the variation within the non-managed care group at physician level, and the hypothesis is not confirmed (3).
Aetna and the Cigna Corporation have millions of managed care patients, but belong to the Health Insurance Association, not to the managed care group.
"We need to get information about the relative clinical effectiveness of drugs so that when we look at price, we can make real evaluations," said Dr. Sharon Levine, associate executive director of Kaiser Permanente, a large managed care group.
She soon leaves that job, finds another at a seemingly more ethical managed care group, is soon disillusioned there and eventually becomes an outspoken public opponent of the system.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com