April 2003

The big packages of the 1990s are long gone. Mergers mean stiffer competition for fewer positions.
Ed Silverman
Can MCOs cope with conflicting demands for cost shifting, comprehensive care, and new services for an extremely influential demographic?
John Carroll
HMOs are not rushing to follow the lead of the largest not-for-profit health plan because they fail to see how this makes them more competitive.
Maureen Glabman
A federal court of appeals says that some benefit denials are really medical treatment decisions. Medical directors, take heed.
Jack A. Rovner
Douglass G. Hewitt
Federal law restricts the leverage given to negotiators for physician associations. Plans should know what is, and what is not, legal.
John W. Jones
The impact of this debilitating disease has been largely underestimated, yet new biologic agents offer significant clinical benefit to those afflicted.
David M. Pariser, MD



Departments
Editor's Memo
John A. Marcille
Legislation & Regulation
Several attorneys general have joined the U.S. Justice Department in questioning some AWP billing and reimbursement practices in Medicaid and Medicare.
John Carroll
Ethics
If a doc is compensated when he schedules a patient visit to convey the routine results of a lipid test, but not when he phones the patient, which behavior will he choose?
Michael S. Victoroff, MD
The Formulary Files
Tomorrow’s Medicine
It is expected that by 2004, 197 biologic medications will be available. Just what kind of an impact will they have on managed care?
Thomas Morrow, MD

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.