Managed Care Reflections: A Q&A With A. Mark Fendrick, MD, and Michael E. Chernew, PhD

Am J Manag Care. 2025;31(12):In Press

AJMC: How have the concept of managed care and the conversations around it changed over the past 30 years?

CHERNEW: Thirty years ago, managed care was new, and all of the related activities to essentially try and improve the way that care was delivered, and have that improvement be done in a way that’s directed by payers, were a really big deal. As health care spending has continued to grow, the non–managed care sector has really shrunk, so now, essentially, everything is managed care. A discussion about managed care 30 years ago was a discussion about a segment of the market; now a discussion about managed care is largely a discussion about the entire market, with maybe a few exceptions in parts of Medicare; for example, traditional Medicare would be an exception, so we have big discussions about Medicare Advantage vs traditional Medicare. But certainly in the commercial space, everything has some level of management, and even in the Medicare fee-for-service space where we don’t have managed care plans everywhere, like Medicare Advantage, what’s happening, increasingly, is adopting more tools that would have been associated with managed care. So the discussion now is much more detailed about the nuances of management, as opposed to the question 30 years ago, “Should there be any sort of broad management by payers of care delivery?”

FENDRICK: As per our usual working together now in our fourth decade, I agree with Mike. I think, just very briefly, when we started as authors and editorial board members and now co–editors in chief, when we talked about managed care in the beginning days, it was capital “Managed Care”—it was a thing—and now, as Mike says, managed care is lowercase in the fact that it’s ubiquitous across all elements of health care delivery. People ask us all the time about the name of the journal. We tend to refer to it as AJMC, as opposed to The American Journal of Managed Care, because as we went through the transitions of the early days of specific managed care to more general managed care, people asked, “Well, aren’t you addressing some of these other things that aren’t specific to those managed care plans that Mike was talking about earlier?” We’re so thankful for what MJH Life Sciences has done growing the discussions around managed care from just the journal to an extraordinarily broad way to communicate these issues.

AJMC: What changes do you see taking place in managed care over the coming years?

FENDRICK: The great Yogi Berra said predictions are dangerous, particularly those about the future, but it hasn’t prevented me from trying to think about what’s going on. I think the main thing as we sit here at the end of 2025 is the role of artificial intelligence—while my children call me artificially intelligent, you can’t go anywhere within the health care sector [without thinking] about how more data and the use of those data will improve both the clinical patient outcomes and the efficiency of care delivery. We’ve seen lots of innovations proposed to us as editors through authors in AJMC. Most of them are really interesting. Very, very few of them have achieved the ambitious goals of saving lives and saving dollars. But I do think that it’s just unsustainable for us to continue to see health care cost growth the way it’s grown over our tenure, and we have to apply various tools that are hopefully clinically driven to allow us to achieve the best clinical outcomes in terms of individual population health, which I care most about as a clinician, but understanding that the system has to be sustainable and economically feasible.

CHERNEW: I agree. I think the changes in care delivery and the extent to which managed care can help ensure that those changes create value, not just more spending, are important and probably the first-order question that managed care plans are going to be grappling with. But I’m going to give you a different answer. If you went back further than 30 years, maybe 50 years, when people talked about managed care, they were really talking about HMOs [health maintenance organizations], and there were some really big, very integrated organizations: Think Kaiser, for example. But the real growth in managed care since then has been in, fundamentally, insurance companies putting together products that fit under the rubric of managed care. So essentially managed care became—for the most part, with Kaiser being a bit of an exception—an insurance term. It was a term that led to how insurers engaged providers, and that was where a lot of the growth in what we call managed care occurred. And going forward, and we’ve begun to see this, there’s now a growing integration between these insurers and the underlying providers. The poster child would be United and Optum, where UnitedHealth Group is a managed care plan. I think we would consider it a managed care plan, although they now have a very large footprint in the delivery system, and you’re going to see that increasingly with other types of historical carriers. Think Aetna, now owned by CVS. Think Humana that owns CenterWell—integration between the insurance function, the care delivery function, the pharmaceutical distribution function. So a lot of these organizations are now integrated with PBMs [pharmacy benefit managers], for example. And so I think what we see going forward is that the definition and the boundaries across market segments that have existed are slowly blurring as organizations get bigger. When we talk about, for example, a large insurance company—think United, think CVS, think some of the Blues in places—when we think about the managing care, it used to mean they were managing the care delivered by providers that were unrelated to them, and now it’s increasingly they’re managing care of providers that they own in varying ways. And although we’re sort of at the beginning of that trajectory, I think the managed care conversation going forward is going to have a much greater emphasis on acknowledging the integration of all these different companies.

AJMC: How has the role of the journal in the managed care information landscape really changed over the decades?

CHERNEW: When we started, the whole MJH enterprise, which has evolved over time, was really focused on the journal, and I think the journal remains a really central part of that enterprise, but now, for a range of reasons, the tools that you can use to convey information to various stakeholders have expanded dramatically. And so AJMC through the peer-review process remains actually relatively similar to the way it was. People write articles, we review the articles, and we publish the ones that are good. For the most part—except no one’s sending around paper manuscripts anymore—that process has remained unchanged, big picture, but the way in which that information gets disseminated—the ability to disseminate the information in a much more targeted way, the ability to engage a broader set of stakeholders through all the various mechanisms that we now have access to—it’s just expanded dramatically. The core distinction is, when we started, we were largely a way of disseminating peer-reviewed research, and now we are a way of disseminating peer-reviewed research plus.

FENDRICK: If you think about the growth of AJMC, we see modest, high single-digit increases in the amount of papers we receive and the papers that we publish. But if you were to take a look at some of the amazing resources that AJMC has put together to celebrate our 30th anniversary, you’d see almost exponential growth in the amount of outputs that are related to the journal, but only indirectly so. An informal way to measure that is that MJH is now in its fifth location, growing each time in terms of needing the resources to not only do what we do for the journal, but in terms of the media communications and the television studio and all the webcasts and Managed Care Minute e-newsletters and all of these resources. I think many of our core readers may not understand what has actually happened regarding the expansion of the AJMC enterprise beyond the journal itself.

I would just really recommend for people who tend to now see AJMC almost exclusively through the website, who search for a specific article, that I think it would be very, very useful for our frequent or infrequent readers who access the journal online to take a little time to look at the table of contents of the journals for the past year. When we started, Mike and I set up a formulaic approach to clinical papers, managerial papers, policy papers, and, rarely, methodologic papers. And what I can say is that being involved with the journal almost for its 30 years, and Mike and I being the co–editors in chief for 2 decades, is the quality of the papers that we receive has improved remarkably over time. When I spend time with the managing editor’s office looking at the papers from 1995 and 1996, I don’t think any of them would have passed scrutiny for AJMC now in 2025.