January 2013

The United States Preventive Services Task Force has recommended against several screenings, yet health plans are finding that it’s not so easy to just drop coverage

Michael D. Dalzell

While there has been movement in many states, health plans would first want to make sure that they wouldn’t be breaking any law

Peter Wehrwein

Extra payments of $1,200 per member per year are being eliminated as CMS seeks to increase competition among plans

A new IOM report urges widespread adoption of innovations. The committee’s chair and the California HealthCare Foundation’s CEO, Mark Smith is working to make that happen.

John Marcille

Despite popular usage, these two terms mean different things, especially when coverage decisions need to be made

Ed Silverman

A CMS demonstration program will determine whether Medicare Advantage health plans improve their quality scores by responding to bonuses that correspond with a five-point rating scale

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD
Scott Guerin, PhD
Overweight or obese patients who participated in a medical nutrition therapy benefit sponsored through their insurer were compared with individuals who did not participate. Outcomes, including weight change, body mass index, waist circumference, and physical exercise, were collected at baseline and 2 years later.
Donald W. Bradley, MD
Gwen Murphy RD, PhD
Linda G. Snetselaar, RD, PhD, LD
Esther F. Myers, PhD, RD, FADA
Laura G. Qualls, MHA



Departments
Legislation & Regulation

The Affordable Care Act requires insurers to measure up if they want to participate in the new state marketplaces for individual policies

John Carroll
Medication Management

Formulary decision makers will probably be disposed favorably toward Xeljanz, the first Janus kinase inhibitor approved for rheumatoid arthritis

Thomas Reinke
Plan Watch

The health plan’s New Hampshire subsidiary rolls out its Compass SmartShopper program to small employers this month

Frank Diamond
Tomorrow's Medicine

For many affected by vitreous degradation, surgery was the only treatment until the development of ocriplasmin

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.