May 2013

Leaders of managed care and of many provider organizations find that they can work together better than ever before

Peter Wehrwein

Physician buy-in and an innovative payment model will keep Cigna’s HealthSpring on course in a changing market, says its president

The Patient-Centered Outcomes Research Institute is getting down to business, thanks to funding that can change care practices
John Carroll

Under Its Alternative Quality Contract, Blue Cross Blue Shield of Massachusetts aims to make global budgets work by having physicians and hospitals cut costs and pursue meaningful quality targets

Joseph Burns

The genomic revolution is under way. Just don’t expect it to be an early money-saver.

Marc S. Williams, MD, FAAP, FACMG

Are you dreaming of a world where mass cancer screenings are discarded as wasteful and personal genetics and ‘big data’ inform individually targeted therapies? Wake up — that world is fast approaching.

David B. Nash, MD, MBA



Departments
Viewpoint

Many health insurance plans face challenges that DTC marketing might be able to address

Ira Studin, PhD, MPH
Medication Management

The association between the two diseases is strong, and insurers should consider all management options

Thomas Reinke
Tomorrow’s Medicine

The Six Million Dollar Man had superhuman eyesight, but insurers won’t have to pay that much for this treatment

Thomas Morrow, MD
Plan Watch

Anthem’s experience exposes vulnerabilities regarding the maintenance of physician networks

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.