MANAGED CARE May 1998. ©1998 Stezzi Communications

MedPartners, the beleaguered physician practice management company, named Mac Crawford president and CEO. Crawford had been chairman and CEO of Magellan Health Services, one of the country's largest specialty managed care organizations. MedPartners also announced that it finished 1997 with a net loss of $821 million, compared with a net loss of $146 million in 1996. MedPartners is in the process of closing 84 clinics, affecting 238 physicians.... Speaking of the CEO shuffle, Stephen Wiggins departed Oxford Health Plans, the company he founded in 1984, with a $9 million severance package, according to company filings. Wiggins left Oxford in February, a result of the HMO's financial and operational problems. The New York attorney general's office is trying to prevent Wiggins from getting the entire package.... The doctors who owned Physician Healthcare Plan of New Jersey sold their 80,000-member HMO to Blue Cross Blue Shield of New Jersey. Today's market makes it nearly impossible to compete against the big players, said Joseph Billotti, M.D., the HMO's former chairman.... The National Committee for Quality Assurance put two new performance measures in the 1999 version of the Health Plan Employer Information and Data Set: cholesterol management after acute cardiovascular events and antidepressant management. In addition, performance on HEDIS measures will count toward a plan's accreditation score beginning July 1, 1999.... The Agency for Health Care Policy and Research is inviting submission of clinical practice guidelines for inclusion in its National Guidelines Clearinghouse, which goes online late this year. Guidelines must have been developed under the auspices of medical specialty associations or professional societies, government agencies, health plans or public or private organizations to be considered for inclusion.... The American College of Physicians has approved a merger with the American Society of Internal Medicine. The merger takes effect July 1, with the combined ACP-ASIM to be headquartered in Philadelphia, ACP's current home. The combined group will have 120,000 members.

--Michael D. Dalzell

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.