February 2008

In the face of stiff competition from a growing category of dedicated wellness companies, major health plans are launching sophisticated, ambitious programs to slake employers’ thirst for these products
Lola Butcher
Employers want to do everything within the law to make workers change their lifestyles, and they expect health plans to help
Frank Diamond
A few major corporations, sometimes with the assistance of a traditional health plan, have made significant efforts to improve employee lifestyles
John Carroll
Legislators are being urged to reward companies that provide programs for their workers, but success has been mixed
Michael Levin-Epstein
The push to mandate this electronic tool is increasing in intensity, but dealing with costs and coming up with standards remain obstacles
Martin Sipkoff
A widespread approach that incorporates various stakeholders may be necessary to change adherence behavior
Sara L. Thier, MPH
Kristina S. Yu-Isenberg, PhD, MPH, RPh
Brian F. Leas, MS, MA
C. Ron Cantrell, PhD
Sandra DeBussey



Departments
Publisher’s Memo
Timothy P. Search, RPh
Legislation & Regulation
Compared to the existing state of affairs, there’s a lot to like in mandatory coverage, but the Massachusetts experiment is a lesson to not expect miracles
John Carroll
Medication Management
A recently announced initiative is supposed to speed approval of generic drugs, but does it address some fundamental flaws in the approval process?
Martin Sipkoff
Tomorrow's Medicine
As the use of biomarkers grows, managed care companies will face tough decisions about setting limits
Thomas Morrow, MD
Plan Watch
Regence’s effort gets nod of approval from physician organization because it allows providers to respond
Frank Diamond

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.