June 2011

Health insurers can be doing more to come up with creative ways to pay providers and organize care
Frank Diamond
With access to large patient populations, health plans are in a position to mine a fresh set of data, but concerns about bias remain
John Carroll
Kaiser Permanente takes on patient safety initiatives in the outpatient setting
For health plans and employer groups, the economics of battling obesity are not always obvious
Richard M. Kirkner
The disease has risen quickly to become the third-leading cause of death in the world — getting there much faster than anyone expected
Bob Kirsch
A comparison of health care costs in patients with diabetes who do not initially respond to oral therapy suggests that it might be appropriate and clinically beneficial for providers to consider adding another oral agent, rather than up-titrating the current medication, particularly beyond intermediate dose levels
Girishanthy Krishnarajah, MPH, MBA/MS
Monali Bhosle, PhD
Richard Chapman, PhD



Departments
Editor's Memo
John Marcille
Legislation & Regulation
The Independent Payment Advisory Board, created by the Affordable Care Act, favors hospitals over health plans
John Carroll
Medication Management
Health plans play a key role in data quality and will benefit from improvements
Thomas Reinke
Plan Watch
Express Scripts’ program manages biologics dispensed under the pharmacy and the medical benefit
Frank Diamond
Tomorrow's Medicine
With Zytiga joining the ranks, managed care may have a way to develop an oncology strategy for a common type of cancer
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.