October 2006

Dealing with that most volatile chemical mix, human beings, means being challenged every day
Maureen Glabman
Health plans seek drug review summaries from other plans, vendors, and online sources
MargaretAnn Cross
In Pittsburgh, new interconnectivity between hospitals and payers reduces expenses and fosters increased coordination of care
Karen Ferrick-Roman
Health care rationing and end-of-life issues may not count in the 2008 election, says this bioethicist. But just you wait.
Patrick Mullen
Doctors and pharmacists who take management positions can find satisfaction, but some return to practice, unhappy with compromises they must make or unable to fit into a corporate culture
Maureen Glabman
Not-for-profit insurers contracting with physician groups provide better results, says one study. What can for-profit plans learn?
Frank Diamond

Editor's Memo
John Marcille
Patients refuse to take responsibility, and every other player in the health care system is reluctant to take charge
Gail Dudley, DO
Legislation & Regulation
Executive order puts new urgency behind an old idea. The federal government is jumping in with both feet and everyone else is expected to follow.
John Carroll
Medication Management
The unlikely partnership between the two could portend the beginnings of an industry trend
Martin Sipkoff
Employer Update
Streamlining the American health care system frees up resources to extend coverage to more people
Lola Butcher
Tomorrow's Medicine
Back in the '40s, patients recovering from cataract surgery were fitted with monofocal lens implants and forced to wear Coke-bottle glasses
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.