October 2004

The idea is radical and simple: Those who need medication the most should pay the least. There is evidence that this is cost-effective.
Martin Sipkoff
How many patients have the intelligence and skills to choose on the basis of medical quality?
MargaretAnn Cross
Along with traditional systemic therapies, the American Academy of Dermatology recommends four biologic agents as first-line treatment for psoriasis patients who are candidates for systemic therapy.
Thomas Morrow, MD
Electronic prescribing needs standardization before it's adopted by the masses. Start with the format of formulary databases.
Tony Schueth
Blue Cross Blue Shield of Montana has hired a third-party patient advocacy company to look into disputes. Looks good for patient satisfaction.
Frank Diamond
You'll spend 12 hours traveling and upward of $2,000 in tuition charges, room and board, then work twice as hard for a week when you get back.
Jaan Sidorov, MD
The HRA is not a new tool, but it is getting new respect. Often prodded by employers, health plans are increasingly identifying at-risk populations.
MargaretAnn Cross



Departments
Viewpoint
Much more research is needed to determine the full effect of drug benefit designs, says the author, an official at AstraZeneca. Quality must be the foremost concern.
Arthur Lazarus, MD, MBA
Legislation & Regulation
CMS has implemented 10 pilot programs that may very well be viewed as a make-or-break test for disease management.
John Carroll
Ethics
Boutique medicine is dysfunctional, but probably not unethical — so long as the lucky patients understand that they're not necessarily paying for better care.
Michael S. Victoroff, MD
Tomorrow's Medicine
Traditional therapies predominate in wound care, but for those patients with chronic conditions, engineered skin may be a welcome relief from pain and infection.
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.