August 2009

Plans and payers are looking at a new insurance design that puts quality first. It might also save money.
Martin Sipkoff
Coverage often straddles the line between the pharmacy and medical benefit, but a properly constructed formulary can bridge the gap
F. Randy Vogenberg, RPh, PhD
Radiology benefit management programs and the launch of new guidelines may slow utilization
Lola Butcher
Unfortunately, most contracts practically invite the companies that health plans deal with to manipulate prices
Linda Cahn
A ‘health insurance czar’ might not make the final bill, if there is one, but the proposal evokes centuries-old tension
Frank Diamond
Legislators are looking closely at ways to prevent fraud and enforce new marketing and educational regulations
John Liethen<br/> and Jonathan Bakewicz



Departments
Editor's Memo
John Marcille
Legislation & Regulation
Just who gets paid for what — and how much — is expected to change in a big way in 2010
John Carroll
Medication Management
The FTC warns that the competition between ‘follow-on’ biologics and the pioneer products is likely to be of the brand-vs.-brand variety
Martin Sipkoff
Tomorrow's Medicine
This competitor of clopidogrel will probably be most useful for patients in the initial phases of acute coronary syndrome
Thomas Morrow, MD
Plan Watch
Retail stores offer “young invincibles” and the working poor the chance to examine low-cost coverage options
Frank Diamond

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.