December 2006

Plans are increasingly concerned about the degree to which providers overcharge them to make up for losses from government programs
MargaretAnn Cross
This nationally recognized expert who has long been frustrated by the pace of change says that — ready or not — health care reform is finally on the way
Now that the value of hospitalists is well established, attention turns to those whose only duties are in intensive care
Lola Butcher
A court case shows what can happen when health plans and provider groups fail to tell the truth, the whole truth, and nothing but the truth
Michael Levinson, MD, JD
If patient involvement is to be a driver of cost containment and improved outcomes, we'll need to think more about just what that really means
Lucy Johns



Departments
Viewpoint
A new survey sheds light on how health plan officials can best present their companies to concerned stakeholders
Alan Hilburg
Legislation & Regulation
Some regional health information organizations are in limbo until the taxman signs off
John Carroll
Medication Management
Officials at the Centers for Medicare & Medicaid Services don't like the idea, but Congress makes the rules (unless the president vetoes them)
Martin Sipkoff
Employer Update
The National Business Coalition on Health has a head start on Uncle Sam's new insistence on transparency and accountability
Lola Butcher
Tomorrow's Medicine
Vaccines for chickenpox and herpes, the two variations of the varicella-zoster virus, are now available for children and the elderly, respectively
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.