November 2004

Nobody doubts that the electronic medical record will promote better medicine, but at what cost? And to whom? Providers fear that they will bear the weight.
John Carroll
If employers make decisions based on URAC's and NCQA's rating of traditional managed care plans, shouldn't they want similar ratings of CDHPs?
MargaretAnn Cross
Congress told the Department of Defense to create a uniform formulary for all the services, and cover all FDA-approved drugs.
Tony Berberabe
Congress's financial review agency says that not enough evidence exists to prove that disease management saves money. Many beg to differ.
Frank Diamond
The FDA stands poised to approve OTC low-dose statins, following a similar change in United Kingdom.
Martin Sipkoff
The idea that everyone in a given geographical area should pay the same for health coverage has come under assault in recent years.
Martin Sipkoff
In this study, outpatient management was effective in controlling nausea and vomiting during pregnancy and was associated with a reduced need for hospital or emergency room treatment as well as reduced costs.
David G. Lombardi, MD
Niki B. Istwan, RN
Debbie J. Rhea, MPH
John M. O'Brien, MD
John R. Barton, MD



Departments
Viewpoint
One important way that we can improve care for people with chronic diseases is to have medical records that are online and accessible when needed.
Jack Ebeler
Legislation & Regulation
The issue is how extensive the list of covered medications should be for the new Medicare pharmaceutical benefit. The stakes are enormous.
John Carroll
Tomorrow's Medicine
New tests will allow better determination of which therapies will work on which patients, thus improving care and reducing outlays for failed therapies.
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.