October 2011

VBID is a promising approach to improving health and cost outcomes, but its use has been limited. Expanding it to complicated interventions will require a lot of effort.
Michael D. Dalzell
The National Business Group on Health’s CEO looks for employers and insurers to collaborate to improve patient safety and cut costs
John Marcille
Once in a while something comes up that requires the sort of immediate and intense intervention that’s downright heroic
Frank Diamond
Lax regulations and fee-for-service payment make an irresistible mix for physician conflicts. Are ACOs the answer?
Richard Mark Kirkner
Medco’s ‘gaps in care’ approach saves $900 million by targeting 15 chronic conditions
Carol Milano
This is no one-size-fits-all solution, as insurers across the country tailor efforts for specific markets
Lola Butcher
A widely available but underused molecular genetic blood test has proved to be accurate over 98% of the time and costs less than $400
Michael Graf, MS



Departments
Editor's Memo
John Marcille
Viewpoint
In a system where people will soon shop for their benefits on exchanges, plans that offer the best customer service will have the edge
Jeff Kang, MD
Medication Management
Health plans are expanding MTM — once considered a Part D mainstay — to their commercial businesses.
Thomas Reinke
Evidence Review
A summary of the ECRI Institute’s Emerging Technology Evidence Report
Legislation & Regulation
The need for health plans to cut administrative costs is hammering insurance brokers. Is this another instance of the law of unintended consequences?
John Carroll
Tomorrow’s Medicine
Brilinta’s price will be a significant factor in coverage decisions when Plavix goes off patent in May 2012
Thomas Morrow, MD
Plan Watch
If UnitedHealth Group’s effort to buy a large physician group proves successful, clinical execs will have even more oversight
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.