May 2006

The problem is outpacing insurers' resources and perhaps even their commitment. Can the chronic care model help?
Martin Sipkoff
The goal of diabetes management is maintaining glycemic control while targeting quality of life improvements
Fadia T. Shaya, PhD, MPH
Gaurav Deshpande, PharmD, MA
It's one of the few areas where plans can economize effectively. BlueCross & BlueShield of North Carolina is one of many insurers that are changing members' and prescribers' behavior.
John Carroll
"How could the largely private U.S. health care system, characterized by arguably more competition than any other health care system in the world, be performing so poorly?"
Can primary care physicians persuade health plans and Medicare to accept their version of the chronic care model?
Michael Levin-Epstein



Departments
Legislation & Regulation
A growing controversy in MedPAC and in physician organizations could spill over into how all health plans compensate doctors
John Carroll
Medication Management
Medication therapy management helps people to stay on their prescribed regimens. Part D plans can expect to start making payments for the service in 2007
Martin Sipkoff
Ethics
Current pay-for-performance programs apply only to a handful of diseases. If we don't pay for all the other diseases, will they get short shrift?
Michael S. Victoroff, MD
Tomorrow's Medicine
While biologic agents can be costly, a new formulation of an old treatment can mean inexpensive and effective relief
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.