December 2010

Placing nearly all specialty drugs under the pharmacy benefit and using tiered formularies are among several promising strategies
Thomas Reinke
Portable interactive communications technology promises to influence health behavior as mere postcards and email messages never did. There will be big rewards for the health plans that figure out how to use it well.
Steven R. Peskin, MD, MBA, FACP
Twitter and Facebook are good places to promote a health plan’s brand, and they can help members by reinforcing positive behaviors
John Carroll
We want to hear from medical directors about how they approach one of the most vexing and chronic problems in health care
Frank Diamond
El Paso First Health Plans did not lose sight of the two goals in the overhaul of the electronic data interchange system
Managed Care Staff
As Part D enrollees approach their coverage limits, their decisions are significantly affected through the doughnut hole period
John W. Hales, MA, PhD
Stephen George, PharmD, MS, RPh

Editor's Memo
John Marcille
Legislation & Regulation
A committee at the Institute of Medicine has called for better use of registered nurses, but physicians continue to try to keep them subordinate
John Carroll
Medication Management
Health plans have another option to consider for improving medication outcomes
Thomas Reinke
Plan Watch
Physicians can earn extra money, but hospitals can lose if they do not show an improvement in quality
Frank Diamond
Tomorrow's Medicine
A new device can partially restore central field vision to thousands who suffer from a common cause of blindness
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.