August 1997

The time lag between when an employee makes a coverage choice and when the plan receives notification from the employer's personnel office can result in expense and problems for patients, physicians and the plan.
Joseph S. Bigley
Now that quality is an industry obsession, it makes sense to find ways of paying your 'best' doctors more. But does 'best' just mean immunizations and a patient-friendly office?
By Deborah Epstein
Not too long ago, disease management was viewed with widespread suspicion. But the evidence mounts that well-designed programs make medical sense and can help patients as well as the bottom line.
Peter Wehrwein
Health plans and physicians have every right to hold down the cost of pharmaceuticals, as long as patients aren't harmed. But not everyone agrees on what actions are acceptable.
Richard R. Abood, R.Ph., J.D.
Accounting for 12 percent of federal spending this year and projected to consume 15 percent of the budget in 2002 if not reined in, Medicare in 1997 is on the road to profound change.
While development of depression management programs has lagged behind other chronic conditions, emphasis is now being placed on early diagnosis and treatment coordinated by primary care physicians.
Jon Ross
You might not expect to hear the term "smoosh" from the lips of one of health care's most erudite observers. But he would argue that the rest of the industry's vocabulary should be as clear.
When Harris Health System began posting losses, it became apparent that a new compensation system, with incentives to providers to control costs, was in order. Risk sharing was the answer.
Neil A. Godbey
On the theory that capitating primary care can lead to unnecessary referrals, a group of California physicians has decided to pay fees to primary care and to capitate specialists. It seems to work.
Shelley Kullman
How do you devise a capitation plan that works? With understanding, hard work and gumption, says the chief financial officer of Sharp Rees-Stealy Medical Group in San Diego.
Keith Alan Moore
Some academic researchers warn that managed care's emphasis on low-cost care means that plans won't support expensive research at academic medical centers. Industry representatives say research is not being ignored.
Joan Szabo
Physicians and hospitals have always been subject to liability claims, but now health plans are becoming vulnerable too. Adverse events cannot be eliminated, but there are many ways to reduce liability exposure.
Allen D. Spiegel, Ph.D., M.P.H. & Florence Kavaler, M.D., M.P.H.

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.