October 2012

For decades, managed care plans have sought to stop paying fees for services. Now they’re trying bundled payments for episodes of care.

Joseph Burns

It might not be the road to totally overcoming the fractured nature of the health care system, but it should lead to better collaboration

Bob Franceschini
Medicaid plans in some states will expand, putting pressure on plans’ primary care networks
Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

Learning these lessons from the Veterans Health Administration, the nation’s largest integrated system, leads to organizational success

Robert L. Jesse, MD, PhD

The researchers find that the costs of treating restless legs syndrome are fairly low, relative to the improved symptoms and associated health care outcomes, and are mainly attributable to prescription medication. Health plans are encouraged to expand coverage to reduce the associated suffering and costs.

Juliana Meyers, MA
Sean Candrilli, PhD
Richard Allen, PhD
Ranjani Manjunath, MPH
Michael Calloway, PhD



Departments
Legislation & Regulation

Hospitals now face stiff penalties and some health plans see this as a way to attain a long-sought goal

John Carroll
Medication Management

Analytical studies, rarely used to evaluate biotechnology products, will need greater attention

Tom Reinke
Plan Watch

Intermountain Healthcare’s checklist for providers cut mortality rates for this fast-moving, and sometimes lethal, condition

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.