March 2003

Purchasers, health plans and, to some extent, enrollees are pressuring providers to use information technology to improve care.
Martin Sipkoff
In a marketplace fraught with downsizing and restructuring, many top administrators find themselves having to change careers.
MargaretAnn Cross
The 11 new measures — as is the case with those already in place — focus on problems that greatly affect their employees, and therefore overall costs.
Frank Diamond
His concepts have been enormously influential in the evolution of the health care system, but the results aren't what he expected. Now he has a new program for saving the system from itself.
Some state officials have real doubts that health plans offer any viable solution to the problem of providing care while budget deficits grow.
John Carroll
Julian Casciano
Karine Amaya, PhD
John Doyle, MPH
Steve Arikian, MD
Neil Shear, MD



Departments
Editor's Memo
John A. Marcille
Viewpoint
By drawing on the expertise of pharmacy benefit managers, managed care plans can teach plan sponsors and brokers the value of pharmacy, and in the process, add to their business.
Todd Gibson
Legislation & Regulation
With today's immense pressure on Medicaid budgets, states can't extend DM programs fast enough.
John Carroll
Legal Forum
The Health Insurance Portability and Accountability Act need not endanger outcomes that depend on data access unless you let it.
Jack A. Rovner

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.