April 2008

A coalition of employers, legislators, consumer advocates, health plans, and drug companies may bring about equal coverage
Martin Sipkoff
The goal is to keep oncologists from relying on drug markups to keep their incomes high, but it’s slow going
Lola Butcher
An experienced negotiator and lawyer describes in detail how health plans that contract with PBMs can get a better deal
Linda Cahn
The company can be expected to be as tough in the PBM arena as in retail, but it has a few hurdles to overcome
John Carroll
A national leader in physician quality improvement believes providers should be judged on the services they provide
The government program is a big — and still growing — business. Millions of members are being enrolled in managed care plans.
Tom Reinke
A system in which individual insurance policies may be purchased for separate medical products and services is based on a medical options market and takes its cue from the financial sector
Damon Douglas, dual PharmD/MBA candidate



Departments
Legislation & Regulation
Hard-charging New York Attorney General Andrew Cuomo says reported rates are neither usual nor customary, nor are they reasonable
John Carroll
Medication Management
Over-the-counter medications can be a good thing for the patient, the insurer, and the pharmaceutical company that developed the product
Martin Sipkoff
Tomorrow's Medicine
Hal Hoffman’s work led to the discovery of the genetic basis of an autosomal dominant disease and to creation of a prototypical orphan drug
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.