July 2005

Regional health information organizations are getting more scrutiny on Capitol Hill. They might hold the key to funding a national online network that links providers.
John Carroll
Stakeholders are pushing for a national clinical trial registry, and efforts by UnitedHealth Group are in the forefront. Medical journals are setting hard and fast rules.
Martin Sipkoff
Looking at past enrollment shifts and at the evolution of managed care can shed light on how to compete in the new market for account-based consumer-directed care, now expected to become one of the predominant health plan models.
MargaretAnn Cross
The plan du jour requires a different mindset and approach in order to succeed. Be sure to include incentives.
Tony Berberabe
Some large health insurers are starting to offer limited-benefit plans (often called mini-meds) for an unexpectedly vibrant niche — the working poor.
John Carroll
Paying for performance promises improved quality, reduced cost, and higher income for doctors. So why are some of them worried?
Martin Sipkoff



Departments
Viewpoint
Pay-for-performance programs imply improved patient care, but are frustrated by fragmented data collection and reporting systems. Think big.
Stanley Hochberg, MD
TOMORROW'S MEDICINE
While the potential of consumer-directed health plans is promising, this design still leaves many questions about coverage unanswered.
Thomas Morrow, MD
Employer Update
Employers and state governments are getting together to design imaginative programs to cover low-pay workers.
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.