December 2003

How medical directors reconcile the contradictory demands of physician and executive roles.
Frank Diamond
As with so much else in health care, observing protocols, analyzing data, and rethinking benefit designs are important.
Martin Sipkoff
In the past, reducing demand for care by raising patients' costs has resulted in the loss of some needed care. Can we avoid the trap?
MargaretAnn Cross
PBMs can do only so much to keep drug price increases in the single digits. Initiatives instituted by health plans can help in this effort.
Tony Berberabe
Improved outcomes with new biologic agents are prompting physicians to integrate them into therapy for psoriasis patients.
David M. Pariser, MD



Departments
Viewpoint
Why don't small employers consider health care quality information the same way large employers do when making benefits decisions? We asked the president of NCQA.
Margaret E. O'Kane
Legislation & Regulation
Three decades after Hawaii was supposed to have put a controversial end to a chronic problem by making employers cover more people, guess what persists?
John Carroll
Tomorrow's Medicine
Maintaining tight glucose control is difficult to accomplish, but adding amylin to the mix may be the answer.
Thomas Morrow, MD
Employer Update
Employers are beginning to tap into the groundswell of employee interest in reducing premiums.
MargaretAnn Cross

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.