February 2009

Providers that once feared insurers’ retribution are finding strength in numbers and compensation in class action litigation
Maureen Glabman
Some of the biggest insurers in the country scramble to make sense of a field that will change treatment techniques forever
John Carroll
DM programs will have amazing patient-monitoring technology at their call. The challenge will be to make good use of the data.
Steven S. Eisenberg, MD
Many experts predict that there will be a dearth of primary care doctors, but others are not so worried
Tom Reinke
Creating truly transparent management systems is in the interest of payers and providers, and is achievable
Emad Rizk, MD
Gary Bazalo, MS, MBA
Richard Weiss, MS
Nathaniel Clark, MD
Berhanu Alemayehu, PhD
Felicia Forma



Departments
Legislation & Regulation
A new administration, new funding, and new commitment might help the system realize a long-sought goal
John Carroll
Medication Management
High quality post-hospital orders can cut readmissions by 30 percent. Medical administrators may soon insist on it.
Tony Berberabe
Tomorrow's Medicine
Until GE found a better way to produce and deliver I123, most nuclear medicine labs had to make do with an isotype that produced an inferior image
Thomas Morrow, MD
Plan Watch
What are some of the common characteristics of health plans that have high scores from the National Committee for Quality Assurance?
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.