Timothy Kelley

Timothy Kelley

There was a time when commentators confidently predicted that Bill Clinton's presidency would stand or fall according to the fate of his administration's ambitious program for reforming health care to guarantee all Americans coverage. That's coverage, remember, and not mere access, as I recall Hillary Clinton stressing in a November 1993 speech that drew sharp distinctions between the Clinton plan and the comparatively milder reform packages offered by Republican Sen. John Chafee of Rhode Island and Democratic Rep. Jim Cooper of Tennessee (packages that look fairly gargantuan in retrospect).

As Americans decide whether to renew Mr. Clinton's lease on the White House, that prediction looks silly. Clinton is way ahead in the polls, and the Clinton plan's loud Capitol Hill belly flop is just something Sen. Dole tries to remind us of. (He's quieter about his own onetime soft spot for the Chafee Plan.)

Luckily, it isn't this magazine's business to read the larger tea leaves. We needn't even decide whether the pollsters are right this time or are headed for a November surprise. But there are aspects of the future we must discuss if we're to do our job. We can only hope to avoid the embarrassment that befell those publications that in 1993 sagely spelled out what would happen "when" — not "if" — comprehensive health reform was enacted.

You'll find four reasonably safe predictions in this issue of Managed Care. Quality measures promulgated by the National Committee for Quality Assurance — and others — will become more demanding. Traditional episodic, fragmented care will give way to "disease management" strategies targeting particular conditions. If medical savings accounts become popular, managed care organizations will find a way to work with them. And finally, the days of keeping clinical data on paper charts are numbered.

The fun, of course, will come in those further developments we can now in no way foresee. Have a pleasant October.

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.