February 2003

A more sophisticated version of a longtime data-gathering tool — the request for information — helps companies gain a clearer picture of health plans' quality-improvement efforts.
MargaretAnn Cross
Bush has one year to deliver change, as promised. Medicare, prescription drugs, malpractice insurance are all on the table.
John Carroll
Paying attention to how elements of the system mingle is crucial for improving quality, says the man who spearheaded the latest Institute of Medicine study.
Health care doesn't use the information technology and training and coordinating techniques that other sectors use.
As health plans and other organizations refine criteria for the practice, consumer advocates voice some concerns.
MargaretAnn Cross
HMOs should adopt a conflict-management, rather than dispute-resolution, approach to patient complaints.
Kathy L. Cerminara, JD



Departments
Editor's Memo
John A. Marcille
Viewpoint
Managed care's strong points, obscured in the backlash over choice and coverage decisions, will be critical to consumers in the years ahead.
Jeff Margolis
Legislation & Regulation
Managed care organizations, concerned that the malpractice-insurance upheaval will thin provider panels and create access difficulties, are watching tort-reform efforts closely. Are we merely seeing the underwriting cycle at work?
John Carroll
Ethics
The American Academy of Family Physicians wants to provide members with some form of electronic medical records. This is downright visionary. Too bad it can't work. One reason: More information means more work for doctors, not less.
Michael S. Victoroff, MD
Legal Forum
The government is closely watching drug companies' marketing practices where they intersect with federal health care programs. While the rules were drafted for drug manufacturers, health plans, too, should be vigilant.
Madeleine A. Estabrook
Systems & Software
Physician demand may finally be on the horizon. The only question is whether the personal digital assistant, smart phone, or another variety will dominate.
Joyce Ochs, MBA
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.