March 2007

Health plans are increasingly involved in promoting the lifestyle changes that help their members avoid cancer, and are increasingly involved in clinical trials if prevention fails
Martin Sipkoff
Increasingly, health plans are providing disease, case, and utilization management when a beneficiary receives a cancer diagnosis
Lola Butcher
Medical care involves choice, and often consumers go with the less expensive option when given all the facts
MargaretAnn Cross
Its 2007 HEDIS physician performance manual puts greater emphasis on cost of care
Tom Reinke
Implementing what was formerly called the Chronic Care Model can improve an organization's response to this widespread problem
Therese Zink, MD, MPH
Karen Lloyd, PhD, LP
George Isham, MD
David J. Mathews, PsyD, LICSW
Terry Crowson, MD



Departments
Editor's Memo
John Marcille
Legislation & Regulation
Battle lines are drawn over proposals to raid the Medicare managed care program of funds to be applied to other health care needs. Democrats themselves are split.
John Carroll
Viewpoint
Blending an approach that uses education, reward, and penalty can rein in runaway health care costs
Louis W. Hutchison Jr.
Medication Management
Widespread adoption of this technology is inevitable, yet physicians still resist. Various coalitions and initiatives are trying to make adoption easier.
Martin Sipkoff
Employer Update
The programs are well received, for the most part, even though it is still hard to measure their value
Lola Butcher
Tomorrow's Medicine
An absorbable polyester material holds great promise beyond its primary use as a new type of surgical suture
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.