February 2006

Enrollment snags could be just the start of political and regulatory headaches facing health plans and pharmacy benefit managers
Martin Sipkoff
With 9% of hospital charges attributable to pregnancy, delivery, and neonatal care, there is considerable opportunity for savings
MargaretAnn Cross
The whole is often greater than the sum of its parts, and that is proving to be the case with health plans. Will we end up with just 4 or 5 competitors?
John Carroll
As hospitals drive growth in programs and health plans take a back seat, this new subspecialty comes into its own
Sharon Baker
Two studies suggest that this design may not be a long-term method for controlling costs
Lola Butcher



Departments
Legislation & Regulation
As we enter a year with a congressional election, candidates are unlikely to stir things up with imaginative, comprehensive proposals
John Carroll
Medication Management
Health plans, with their view of the complete spectrum of patient care, are in a unique position to identify problems with polypharmacy
Martin Sipkoff
Tomorrow's Medicine
B-cells and their markers, once overlooked in the pathophysiology of rheumatoid arthritis, may hold the key for a new treatment regimen
Thomas Morrow, MD
Health Plan Design
Aetna, Cigna, Humana, and others are taking a variety of approaches in supplying information to members who are paying more out of pocket
Lola Butcher

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.