September 2004

As rising costs drive CEOs' collective blood pressure off the charts, a group of experts considers whether managed care has reached another watershed — and whether the industry can reinvent itself yet again.
John Carroll
The head of the National Committee for Quality Assurance says health plans want to encourage physicians in the never-ending quest for quality.
People flock to these services whether insurers cover them or not. When does it make economic and medical sense to offer them?
Sherrie Dulworth, RN
Physicians are not the only problem. Health plans too often view guidelines as rigid routines rather than flexible aids to good practice.
Tony Berberabe
Although interactive educational seminars that target physicians require a large investment of resources, they can be cost-effective if medical care is improved as a result.
Michael D. Cabana, MD, MPH
Randall Brown, MD, MPH
Noreen M. Clark, PhD
Diane F. White, RRT
Juanita Lyons, PhD
Presenteeism — the condition of being on the job, but giving less than 100 percent — is fertile ground for health plans with a suitable product.
MargaretAnn Cross



Departments
Legislation & Regulation
The pharmaceutical giant contends that soon-to-be-released data will verify its program's effectiveness.
John Carroll
Tomorrow's Medicine
An important federal law encourages development of drugs for populations so small that the market would otherwise ignore them. Should they not then be covered?
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.