August 2003

For now, consumers are willing to pay extra for direct access. How long that continues is linked to whether old practice habits can be broken.
Frank Diamond
There's more than one way to skin a cat, but all are not equally good. Is it time for another look at managed competition?
Martin Sipkoff
Health plans are taking profitable cues from national retailers and providing members with coupons for newly available over-the-counter products.
Tony Berberabe
Plagued by higher costs and the need to provide at least bare bones coverage, more companies, and smaller ones, are self-insuring.
John Carroll
"If I were queen of managed care...," muses the president of the New England Healthcare Institute, who wants to see how new technologies fit in with the entire system, not just pieces of it.
HMOs would be wise to use profits from the last six years of growth to position themselves to compete in an altered marketplace.
Bob Carlson



Departments
Legislation & Regulation
The government wants to build an electronic system through which insurers, physicians, and hospitals can communicate. Snomed CT may solve a lot of problems.
John Carroll
Ethics
When we all show signs of the same syndrome, we may not easily admit that it is a problem. What about a prevalent practice that kills?
Michael S. Victoroff, MD
Tomorrow's Medicine
The evolving modality of PDT gives patients with premalignant lesions of the esophagus reason to hope. Managed care must update existing policies.
Thomas Morrow, MD
Employer Update
As health care grows as a share of business costs, enlightened execs are urging plans to work with them in keeping employees at their posts and performing at 100 percent.
MargaretAnn Cross
Managed Care Outlook

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.