July 2008

As doctors increasingly go to work for hospital systems, care might become more organized and effective, but plans could lose bargaining power
Lola Butcher
Use of aggressive techniques to encourage patient adherence saves and improves lives and controls costs
Martin Sipkoff
The Genetic Information Nondiscrimination Act will have a profound effect on insurers, even if we’re not quite sure what it will be
John Carroll
Leapfrog’s revised length-of-stay measure is an early and welcome attempt to measure hospitals’ efficiency
Tom Reinke
Anthem Blue Cross & Blue Shield bets that focusing on this portion of the individual market might be a good way to build brand loyalty
Frank Diamond



Departments
Viewpoint
Initially, Part D offered so much to so many who needed help. Now the program is straining under its own weight.
Tom Kaye, RPh, MBA
Legislation & Regulation
These giant Internet players can offer the fluidity of personal data and information, but they don’t have to comply with privacy standards
John Carroll
Medication Management
Employers have implemented a number of methods to slow down prescription drug costs, but waiving copayments for chronic conditions has yet to enjoy widespread use
Martin Sipkoff
Tomorrow's Medicine
Commercial and public payers concerned by prolonged hospital stays will be considering this μ-opioid antagonist
Thomas Morrow, MD
Plan Watch
Health plans should look into why medical centers that spend the most per capita don’t necessarily deliver the best care
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.