September 1997

Why can't patients understand managed care information? Too often, printed materials baffle them because authors don't take into account literacy level, reading skills, thinking style or short-term memory.
Mark Hochhauser, Ph.D.
In Virginia, sheer persistence helped a large family practice group forge a partnership that provides the capital for full-risk contracting without requiring subservience.
In Minnesota, a joint venture between two family practice groups is reclaiming for family doctors the power to decide which specialists and hospitals to send their patients to.
In California, multiyear "evergreen" HMO contracts are one ticket to greater operating autonomy for a large medical group created by a recent merger.
Joan Szabo
In Florida, one physician group believes trading away a measure of financial independence to a physician practice management company has actually given it more clout where it counts.
Jean Lawrence
For physicians, reclaiming a measure of clinical autonomy can be a matter of health itself. But alas, there's no one blueprint to follow.
Jean Lawrence
For both physicians and health plans these days, it's imperative to make sure patients are satisfied "customers." But just how can that be done? Our reporter attended a workshop in Wisconsin to find out.
Bob Carlson
If you've ever grumbled about how the press plays up one tragedy while ignoring millions of successes, you won't enjoy reading this. But you should. There's a lesson here about managed care's failure to tell its story effectively.
William Sherman
Applying the principles of industry to the practice of medicine has occurred to a number of people at different points in their careers. It hit David Nash in high school.
Backers hope that provider-sponsored organizations will offer some pretty strong competition to conventional Medicare and Medicaid HMOs. Opponents claim PSOs have been given an inappropriate advantage.
Gary Scott Davis, J.D.
Organizations such as NCQA are grading managed care plans on many aspects of care and making the results public. Health plans, in turn, are evaluating physicians. Here are some suggestions for making the grade.
Carolyn Buppert, C.R.N.P., J.D.
The national goal is to immunize 90 percent of children under 2 by 2000, yet today the rate is still only about 75 percent. To meet the target, health plans are employing a variety of new techniques.
Debra Hughes

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.