April 2007

Health plan consolidation has its upside, but some who contract with insurers see only the downside
John Carroll
Contracting advantage has sometimes been with the nationwide labs, but health plans are getting serious about price, service, and patient data
Scott Kober
Health care economists and others imagine a society in which managed care had never been invented
Frank Diamond
Plans and PBMs are divided about sharing drug prices with clinicians. Is it better to have an administrative committee determine the formulary?
MargaretAnn Cross
Mostly it is self-insured employers that are offering the option, but health plans may well want to join in
Lisa A. Higgins
The man who heads McKesson Health Solutions, the third largest disease management program in the country, says it's time to roll out a new model



Departments
Viewpoint
The history of HMOs has been one of conflict between plans and physicians. Could global specialty capitation be a better way?
Daniel Y. Patterson MD, MPH
Legislation & Regulation
Sufficient confidentiality needs to be assured before a nationwide system will be ready for implementation
John Carroll
Medication Management
The Access to Life-Saving Medicine Act may be a first step to giving the FDA the legal authority to approve these drugs
Martin Sipkoff
Health Plan Design
Expecting people to enter the health insurance marketplace and function as savvy buyers is unrealistic
Lola Butcher
Tomorrow's Medicine
Today's high-tech artificial joint has changed the outcomes for many who have suffered a fractured hip
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.