November 1997

The first comparative report of health plan performance produces surprising revelations — and a starting point for assessing a plan's quality. But some people caution not to read too much into the numbers alone.
Michael D. Dalzell
Contrary to many experts' predictions, per-member, per-month prepayment of managed care physicians isn't sweeping the nation. But it can't be counted out, either.
Peter Wehrwein
Between fee-for-service payment and pure capitation, health plans are developing several alternative means of paying specialists. So-called "contact capitation" is one of them.
Bob Carlson
Will global capitation be the means of reducing HMOs to the status of third-party administrators? Experts differ on that one. But they agree that capitation, in its various forms, is here to stay.
Jean Lawrence
It didn't take a seer to predict that states would try managed care on their costliest health mandate. But only a seer today can be sure whether physicians will be able to live with Medicaid risk contracts.
Cliff Collins
History has vindicated Paul Ellwood's prediction of a price-competitive health care market. Is he right again in saying the current trend away from integration will be reversed?
Zeneca Pharmaceuticals convened a roundtable of five experts in August to discuss the transformation of Medicare into a more flexible, multi-option system that loosens restrictions on physicians. They paid particular attention to the changes just enacted in the Tax Reform Act of 1997.
Way back when, credentialing was something done only by hospitals. Now, nearly every health plan must do a check on every physician. The AMA has a plan to lighten the burden. But will it work for all parties?
Joan Szabo

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.