Timothy Kelley

Timothy Kelley

I once did some volunteer work for an idealistic young candidate who was running in a primary against a man I'll call Congressman X. X, an influential legislator, had been tainted by the Abscam scandal of the late 1970s, and that perceived vulnerability had also drawn two latecomers into the race. I still recall the remark of a wizened observer in the back of the hall at a candidates' debate shortly before the incumbent squeaked through to renomination. "You might be able to beat Congressman X," the man said. "But not with three candidates!"

I thought of that remark while reading about Propositions 214 and 216 on this month's California ballot. Both were aimed at perceived abuses in managed care, and both looked like losers as Election Day neared. One reason: As the Wall Street Journal reported, "proponents of the two initiatives seem to devote as much energy [to] attacking each other as they do [to] their mutual opponents." Another factor working against the two California propositions was the voters' overall mood. Analysts say 1996, unlike '92 and '94, isn't likely to be a bad year for incumbents. And in California, managed care is by now so entrenched as to have assumed the character of incumbency.

That's also true up the coast in Oregon. Because of our deadlines, readers of this page have the advantage over me in knowing the numbers in the lower right hand corner of our cover — the vote tally on Salem ophthalmologist Gordon Miller's Measure 35. Defeat seemed in store for that initiative, too. But we considered Measure 35 worthy of a closer look, because it dealt not with gag rules, gatekeeping or 48-hour maternity stays, but with capitation, a payment mechanism at managed care's core.

By now, surely, even the hardiest citizens are tired of politics. But the political process has the power to change the rules of managed care. We present our article on the implications of the Oregon vote (page 26) in the belief that, whatever this fall's results, the views of patients as voters can't be safely ignored.

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.