February 2014

Rates are far too high, and health plans are big losers. Is it time to institute financial penalties?

Joseph Burns

Insurers want to obey laws, but those laws are hard to understand and it is tempting to simply define coverage equality downward

Joseph Burns

But not just nursing homes. The former CMS chief wants to create efficiencies in all post-acute care settings, and looks to health plans as customers.

Can an injectable biologic really replace a delicate surgery for treatment of Dupuytren’s disease?

Jack McCain

A bigger portion of the population is expected to have cardiac disease but live longer, and researchers argue for stopping it before it shows

Frank Diamond

Moody’s says that more people will get care, but hedges its prediction, while other experts think that the trend line will stay flat

Frank Diamond

A new precertification procedure addresses key elements in genetic testing

Thomas Reinke



Departments
Legislation & Regulation

The system’s effect on the private sector has actually been underestimated. Medicare price changes often lead to amplified swings on the private side.

John Carroll
The Wider View

Compulsory medical insurance with a twist: Plans play a crucial role

Robert Royce, PhD
Plan Watch

Despite last year’s fiasco at Penn State and growing concern about the effectiveness of such programs, employers are still believers

Frank Diamond
The Formulary Files
Krishna R. Patel, PharmD, RPh
Tomorrow's Medicine
Genome squencing has gotten so cheap that it takes oncologists’ breath away. It also raises thorny issues for health insurers.
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.