May 2003

Businesses are relying on doctors to direct the health benefit. They often work directly with plans to keep workers healthy — and at their posts.
MargaretAnn Cross
Most would not want health care to go through such a major change unless it became a question of survival. Many say that's just where we are.
John Carroll
Many health plans see real value — financial as well as social — in screening for victims.
MargaretAnn Cross
Partly because of employers' demands, health plans are starting to cooperate in ways that improve care.
Martin Sipkoff
The executive director of the Leapfrog Group says that the organization pleads guilty to trying to create 'aspirational' standards for health care.
Do more with less — that's what we all must learn. In the physician's office, when patients share their doctor's time, everyone benefits.
Bob Carlson
Many labor organizations have been isolated from inflationary realities. Can health plans and employers make them see the light?
MargaretAnn Cross
The appropriate application of criteria for the use of palivizumab can save health plans a significant amount of money.
William Silverman, MD, FAAP



Departments
Editor's Memo
John A. Marcille
Viewpoint
The long-term impact of noncompliance must be considered before copayments are increased. This is especially true where chronic conditions are concerned.
Wayne Miller, RPh, MBA
Legislation & Regulation
The managed care industry says that the ramifications of the Supreme Court decision will be slight. But could that be just wishful thinking?
John Carroll
Ethics
Physicians, teachers, and clergy are among those professions that enjoy particular respect. They must preserve equanimity in the face of ephemeral social movements.
Michael S. Victoroff, 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.