September 2013

Delayed deadlines don’t alter the reality that you need to be ready for the big changes

Timothy Kelley

Mental illnesses are being redefined as science advances, but don’t believe reports of a war between the APA and the NIMH

Susan Worley

Insurers can block a lot of crime, but the ACA and ICD-10 promise to make the fight against dishonest doctors even tougher

Frank Diamond

Nine Pioneer ACOs have dropped out of the elite program but there are true believers among the survivors

Peter Wehrwein

A survey reveals lack of awareness that stands in the way of more effective benefit design for these often expensive medications

F. Randy Vogenberg, PhD, RPh
Cheryl Larson
Margaret Rehayem
Larry Boress

There are some basic approaches health insurance plans can use to create better odds for cost-efficiency

Scott Schell, MBA, MD, PhD



Departments
Legislation & Regulation

Insurers looking for some financial relief hope that the people who run the FDA’s review process take note

John Carroll
Medication Management

The tools are imperfect. Even so, physicians and patients are not taking advantage of practices that save lives.

Thomas Reinke
Plan Watch

Providers are not the only ones who need to encourage employees to get more involved with their care, a study argues

Frank Diamond
Tomorrow's Medicine

This method of matching drugs to patient starts with RA but may eventually be used for many other conditions

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.