May 2010

A huge influx of enrollees gives insurers a chance to demonstrate cost-saving techniques developed over the years
Frank Diamond
First, which members are affected? The question is simple, but getting the answer might not be.
Kendra Obrist
New accreditation standards make it possible to do in physicians’ offices what’s now being done in hospitals — at significant savings
Rock Rockett, PhD
Health plans see value in rewarding physicians for participating in their specialty boards’ maintenance-of-certification programs
Richard Mark Kirkner
Health insurers and plan administrators will have to emphasize quality and cost management, says Cigna’s chief medical officer
Swine flu had us all pretty worried a year ago, but preventive measures seem to have done their job
Tony Berberabe
A program that outlined the concepts of evidence-based medicine improved residents’ knowledge about treatment costs
Greg P. Marconi, MD
Alan L. Nager, MD, MHA



Departments
Editor's Memo
John Marcille
Legislation & Regulation
Recession-minded regulators don’t like this year’s proposed rate hikes. Just try telling them that the increases are based on actual rising costs.
John Carroll
Tomorrow's Medicine
If clinicians could get a earlier warning, there often would be time to forestall a full-blown ‘brain attack’
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.