August 2004

The accepted insurance model is to provide care intended to make sick people well. This might include screening, and some preventive actions such as immunizations. But there are new arguments that small investments in persuading people to live healthier lifestyles will result in large reductions in cost in later years.
MargaretAnn Cross
Now that tiered formularies rule the land, what many suspected is being demonstrated: Compliance is suffering and so, too, are patients.
Martin Sipkoff
Deciding to seek NCQA accreditation sets an HMO up for lots of preparatory work. Make sure the effort is well spent.
Bob Carlson
Physicians who make the move to the administrative side find a lot of tough decisions waiting for them.
Marilyn Bydalek
Yes, health care is a business, but altruistic plans would like to cooperate with others. The Leapfrog Group has set up a simple mechanism to do this.



Departments
Viewpoint
Only a small percent of a typical health plan's population takes medicine for conditions outside the generalist's scope. But it's a big portion of the drug bill.
Alan Lotvin
Ethics
When physicians think it is acceptable to withhold care from lawyers involved in malpractice suits, does it signal a breakdown of the social order?
Michael S. Victoroff, MD
Legislation & Regulation
The senate majority leader, a surgeon who owns a large stake in a chain of hospitals, puts forth far-reaching proposals for reforming the health care system.
John Carroll
Employer Update
Companies test new approaches to funding the pharmacy benefit with the goal of saving money overall.
MargaretAnn Cross
TOMORROW'S MEDICINE
Diseases will soon be defined by biochemical pathways and genetic interactions. Biochips may identify patients likely to respond to therapeutic agents.
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.