July 2003

The concept is not new, and there might not be total truth in advertising, but it is rapidly gaining acceptance as a technique to control costs and disease progression.
Bob Carlson
Health plans know that getting along with physicians is important, and many are trying new initiatives. Here are some successes.
Ed Silverman
Some plans swear by the benefits of obtaining an "excellent." Others say that customers care much more about cost.
MargaretAnn Cross
Change comes slowly, says this public policy expert whose work over the last two decades has helped frame the health care debate. She'd like to see greater efforts in the public and private sectors to reward quality.
Patrick Mullen
Continuous subcutaneous terbutaline infusion shows improved clinical outcomes and decreased nursery costs compared with oral tocolytics in women with recurrent preterm labor.
Fung Lam, MD
Niki B. Istwan, RN, BS
Debbie Jacques, MPH
Suzanne K. Coleman, RNC, MS
Gary J. Stanziano, MD



Departments
Viewpoint
Mentors and support groups can help you avoid being fired. And if the worst does happen, they can facilitate your comeback.
Arthur Lazarus, MD, MBA
Legislation & Regulation
Have drug companies lost the incentive to develop products for small populations? What's managed care's stake?
John Carroll
Ethics
The current debate over a single payer system calls to mind the parable of the blind men describing an elephant.
Michael S. Victoroff, MD
Tomorrow's Medicine
By reducing restenosis, these devices will save managed care money.
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.