May 2005

In theory, consumer-directed health plans put the reins of decision making into the hands of their members. But medical management departments are alive and well inside CDHPs — and may even expand under these plan designs.
MargaretAnn Cross
Not only can health plans pay for performance, they can offer a mechanism for confidential discussions of mistakes.
Frank Diamond
With big companies steadily reducing coverage for retirees, plans need to devise products for this needy population.
John Carroll
This expert who hopes to help everybody adjust nevertheless expects big headaches come Jan. 1, 2006. However, e-prescribing could make the drug plan work.
Patrick Mullen
Integration of predictive modeling and genomic tools means improved technology, enhanced databases, and appropriate legal guidance.
Martin Sipkoff



Departments
Legislation & Regulation
David Brailer, MD, PhD, the nation's health information chief, wants the industry, not the government, to devise a system that provides interoperability.
John Carroll
Medication Management
Despite the seeming Gordian knot of regulations associated with Medicare Part D, health plans figure the benefit-to-risk ratio is squarely in their favor.
Martin Sipkoff
Ethics
Is using the tort system and class action lawsuits the best way to solve problems between business professionals? That and $54.37 can go toward the creation of a foundation to bring about meaningful organizational change.
Michael S. Victoroff, MD
Tomorrow's Medicine
Recent advances in pain relief revolve around longer-lasting implantable devices. Can you afford not to have a pain management strategy?
Thomas Morrow, MD
Managed Care Outlook
Opinion leaders say Congress should also act to improve quality and safety, and ensure Medicare solvency.

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.