April 2005

After years of short shrift from payers and insurers, substance abuse services get renewed interest. Health Plans in particular are re-evaluating their approach.
Martin Sipkoff
Health plans have much at stake as Congress moves to lay down the do’s and don’ts about use of info gathered via genetic testing.
Michael Levin-Epstein
The feds will help you launch a health plan for the elderly, but just what does it take to get something like this operating in so short a time?
Frank Diamond
Cadillac or Yugo care for the poor? Fee-for-service or managed care? The states have a lot on their minds as the Medicaid monster grows and grows.
John Carroll
This study is the first to estimate costs and medical resource use associated with restenosis involving bare metal stents in managed care percutaneous coronary intervention patients.
Mary Ann Clark, MHA
Ameet Bakhai, MD, MRCP
Elise M. Pelletier, MS
David J.Cohen, MD, MSc



Departments
Legislation & Regulation
More and more health plans are being told that they need to do good if they want to do well. Is this fair? Are other industries forced to make charitable donations?
John Carroll
Medication Management
The e-prescribing movement is getting some new advocates --employers. Can the combined influence of plans, employers, and the government affect physician buy-in?
Martin Sipkoff
Tomorrow's Medicine
As new specialty pharmacy care becomes more dominant, companies devoted to managing these products and their associated costs are finding a market.
Thomas Morrow, MD
Employer Update
Disease management conference focuses on outcomes measures that address issues such as presenteeism that concern most health care purchasers
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.