Research Articles from Managed Care

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Santosh J. Agarwal, BPharm, MS; Gary V. Delhougne, JD, MHA; Levi Citrin, JD; Jill E. Sackman, DVM, PhD; Anthony J. Senagore, MD, MS, MBA
Angela K. Hochhalter, PhD; Rashmita Basu, PhD; Karim Prasla, PharmD; Chanhee Jo, PhD
Andrea DeVries, PhD; Gosia Sylwestrzak, MA; Abiy Agiro, PhD; Thomas Power, MD

UM for outpatient discretionary echocardiography appeared to reduce testing rates significantly

Kathryn S. Kolibaba, MD
Although this practice can optimize long-term patient outcomes, it is not routine in clinical practice
Navin K. Singh, MD; Nancy L. Reaven, MA; Susan E. Funk, MBA

There was little difference between the options in terms of the frequency and cost of return visits. Patients receiving one-stage reconstructions returned slightly less often for breast-related services during the first 18 months after reconstruction, but the difference was not statistically significant.

Donald W. Bradley, MD; Gwen Murphy RD, PhD; Linda G. Snetselaar, RD, PhD, LD; Esther F. Myers, PhD, RD, FADA; Laura G. Qualls, MHA
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.
Nicole C. Ferko MSc; Natalie Borisova PhD; Parisa Airia, PhD; Daniel T Grima, MSc; Melissa F Thompson, MBA
Using case studies, researchers assess the effect of rebate rates on the cost-effectiveness of two oral bisphosphonates that are competing for tier 2 positioning
Juliana Meyers, MA; Sean Candrilli, PhD; Richard Allen, PhD; Ranjani Manjunath, MPH; Michael Calloway, 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.

John Barron, PharmD; Ralph Turner, PhD; Michael Jaeger, MD; Wallace Adamson, MD; Joseph Singer, MD

Patients treated with oral linezolid, covered under the pharmacy benefit, had lower re-hospitalizations and emergency room visits than patients treated with vancomycin or daptomycin, covered under the medical benefit

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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.