April 2010

It depends partly on whether the population is rural or urban and whether utilization can be controlled
John Carroll
A longtime advocate is still betting on a single payer system because, she says, the new reform law won’t come near to doing what’s needed
When many randomized trials are badly done or irrelevant, what are formulary managers and committees to do?
Ed Silverman
When physicians lack sufficient preparation, they are frustrated, and their relationships with insurers can suffer
Frank Diamond
Multiple cost cutting strategies zero in on every aspect of physician remuneration
Thomas Reinke
Risk adjustment is part of the reform package, but other countries have had problems with implementation
Richard Mark Kirkner



Departments
Viewpoint
A physician argues that the health care system cannot be truly reformed unless enrollees open their eyes to the facts of healthy living
Gail J. Dudley, DO
Legislation & Regulation
HIPAA was all bark when it came to penalties for failing to protect personal health and financial records. HITECH is already showing some bite.
John Carroll
Medication Management
Sometimes the cure can pose the biggest threat, the data suggest
Martin Sipkoff
Plan Watch
UnitedHealthcare and Towers Watson team up to capture the business of employers who provide coverage for former employees
Frank Diamond
Tomorrow's Medicine
A fatal disease with many victims, IPF has been shown to progress more slowly when treated by pirfenidone. The FDA itself has not yet ruled on it.
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.