May 2012

Two vaunted ideals of health care, experts say, should be perfectly aligned. And they almost are.
Timothy Kelley
When drug manufacturer coupons make members’ costs for brand drugs equal to generics — or less — health plans, employers, PBMs, and members pay a price
Linda Cahn
As expensive products increase their share of the medication market, expect these methods to be employed widely
Ira Studin, PhD, MPH
When 32 million or more new members, courtesy of the Accountable Care Act, are just not enough
John Carroll
Even though accountable care organizations have not lived up to their promise, some will ultimately succeed
Richard Stefanacci, DO, MGH, MBA, AGSF, CMD
A review of the available research identifies payment for services in the absence of high-quality scientific evidence and presents an opportunity to use evidence-based medicine to develop a clinical coverage guideline
James P. Reichmann, MBA
Michael S. Kirkbride, BSc, Pharm D



Departments
Editor's Memo
John Marcille
Legislation & Regulation
Plans will compete for new enrollees, including people with major health problems
John Carroll
Medication Management
Also called observational research, these studies dig down to the provider and patient level rather than analyzing only population-level data
Thomas Reinke
Plan Watch
Young women on Medicaid tend to skip physicals because of child care concerns. One insurer thinks it might have an answer.
Frank Diamond
Tomorrow's Medicine
This screening tool is less invasive than a colonoscopy, with a specificity approaching 99 percent as risk increases
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.