Timothy Kelley
MANAGED CARE July 1997. ©1997 Stezzi Communications

Timothy Kelley

We planned it this way, of course. The magazine you hold in your hand is a vast, comprehensively interlocking mechanism of Swiss-like design, each gear delicately calibrated, each peg precisely grooved and fluted, the whole an awesomely purring informational machine.

Our cover article, "Whatever Happened to Exclusive Contracting?" (page 36) discusses a onetime Jackson Hole Group vision of managed competition — each health plan with its dedicated providers — and why it has so far failed to come true. One inspiration for that vision, of course, was the early staff-model HMOs. Even they are now moving away from full reliance on exclusive provider relationships. And so, with the kind of subtle coordination with which this issue is replete, we also explore recent changes at three of these historic HMOs in "Pioneer Not-for-Profit Plans Struggle To Remain Leaders" on page 48.

We knew, of course, that consultant Lucy Johns was going to tell cover-story author Jean Lawrence that current payment systems offer physicians "a substantial opportunity to cost-shift onto Medicare." We also knew that bills trimming Medicare growth and offering new managed Medicare options would be the hot item in the capital as we went to press (Washington Initiatives, page 18). So we planned an article on Medicare's HMO payment methodology and the possible effects of changing it ("Projecting a Leaner Managed Medicare," page 83). Such was our grand design that we also assigned writer Peter Wehrwein to prepare a chronology of a Louisiana HMO now making a big push in the Medicare market ("Diary of the Birth of an HMO," page 69.) Letter-writer C. Papas, M.D., (page 8) may even have sensed that the Employee Retirement Income Security Act would be the subject of a new Texas law (State Initiatives, page 20).

Others may slack off in summertime, but not us.

We did it all on purpose.

And if you believe that . . .

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.