October 2005

Politicians on both sides of the aisle are considering this as a way of fixing the system. What might it mean for health plans?
Martin Sipkoff
Medical directors are charged with many of the tasks that could help members make the most of consumer-directed health plans
MargaretAnn Cross
Some insurers seem to have a knack for irritating their network physicians. The list is long, but five categories of irritants seem to recur most often.
Bob Carlson
As we learn which supplements are truly beneficial, is limited coverage of specific products in the works?
Sharon Baker
Offering 17P as a benefit to pregnant women enrollees with a history of preterm delivery can reduce NICU days significantly for a Medicaid plan.
Mary V. Mason, MD, MBA
Kara M. House, BS, MBA
Cathy M. Fuest, RPh
Deborah R. Fitzgerald, RN
Bonnie J. Kitson, MBA



Departments
Ethics
Complacent bureaucracies could not answer the call. Now is the time to make adjustments. The next shoe will drop.
Michael S. Victoroff, MD
Legislation & Regulation
Some of the biggest insurers in the country will do whatever it takes to promote their offerings under Medicare's new prescription drug benefit
John Carroll
Medication Management
Their presence in the public sector could lead to a strong presence in the private sector. Is a managed care backlash looming?
Martin Sipkoff
Tomorrow's Medicine
Enhanced management continues due to a greater understanding of the intricate glucose balance and the shortfalls of existing medications.
Thomas Morrow, MD
Employer Update
A medical device manufacturer, Definity Health's first client nearly 5 years ago, has moved a fourth of its employees into the new-style plan
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.