August 2012

Under health reform, consumers will be the new buyers in public and private exchanges, meaning care management programs will need a sharper focus on return on investment

Joseph Burns

As providers scramble to form accountable care organizations, insurers take steps to either participate, or limit ACO market power

Thomas Reinke

ACOs can learn from successes and mistakes of managed care, says Kaiser Permanente physician leader

John Marcille

While the United States has been in turmoil over how to tame its excessive health care bill, the Brits have their own problems — different, but in some ways the same

Robert Royce, PhD

In large part, the growth of specialty pharmacy will require pharmacy benefit managers to become more active on behalf of payers and patients

Warren K. Williams



Departments
Legislation & Regulation

In nonconforming states, health plans will miss out on a bonanza of new members and hospitals might be on the hook for uncompensated care

John Carroll
Medication Management
The Food & Drug Administration’s approach to this stage of a drug’s life cycle is inadequate
Tom Reinke
Evidence Review

Many insurers have not yet updated their coverage policies since the FDA cleared this scanning tool in November 2011

Plan Watch

Blue Cross Blue Shield of Michigan teaches effective interviewing techniques to nurses on the front lines of chronic disease

Frank Diamond
Tomorrow's Medicine

Clinical trial data from the lorcaserin submission suggest modest weight loss over a short period

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.