March 2004

In the bad old days, health plans would contract with a limited number of providers, promising them lots of work in return for low prices. Now, a new generation of narrow networks takes a page from the old HMO playbook, adding fresh comparisons on quality that all providers will find hard to ignore.
John Carroll
If everyone can see what everyone is doing, we'll have better care at lower costs. First task: Create common standards.
Martin Sipkoff
There's a big push for passage this year, but don't hold your breath. Many feel that such a measure would be too expensive.
John Carroll
Initial results are promising. Employees turn toward preventive medicine and away from expensive drug therapies.
MargaretAnn Cross
Y2K, 9/11, anthrax scares — these events crystallized the problem of medication stockpiling. How does managed care respond?
Tony Berberabe
Omalizumab, a novel therapy that targets specific steps in the inflammatory cascade of asthma, may benefit the hard-to-treat patient.
Gailen D. Marshall Jr., MD, PhD
Christine A. Sorkness, PharmD



Departments
Legislation & Regulation
Federal backing aligns with market pressure to create an irresistible force. However, health plans need to be aware of some troubling issues.
John Carroll
Ethics
It's easy to blame the uninformed, and sometimes fair, but are the ignorant the only ones at fault? Medical professionals need to be able to explain, not just order and direct.
Michael S. Victoroff, MD
Tomorrow's Medicine
Improvements in the features of diabetes pumps have evolved since their original backpack-size days. Managed care needs to evaluate the new bells and whistles.
Thomas Morrow, MD
Employer Update
Pepsi promises that work-site clinics won't take business away from health plans.
MargaretAnn Cross

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.