John A. Marcille

Physicians often find that to survive and prosper under managed care, they must meet new requirements whose necessity they may not, in their secret hearts, concede.

We all know that there is a certain amount of suspicion of capitation, utilization review, length-of-stay limits and — well, you get the picture. We know, too, that some physicians are skeptical of managed care organizations' oft-repeated pledge to deliver high-quality care.

Wouldn't it be nice for plans, patients and physicians to be able to pull in the same direction, at least some of the time?

Our cover story sets out one area in which this ought to be possible. Anecdotal evidence and academic research both indicate that many physicians don't listen to patients carefully enough, and that the consequence is cost- ineffective medicine in the form of premature diagnosis and inappropriate treatment.

Let's accept the premise. As contributing editor Chuck Appleby found in researching the problem, physicians definitely can improve their listening skills. Good-listener classes provided by for-profit and not-for-profit groups have been able to change behavior quickly and easily.

When doctors listen better, patients are happier. Outcomes, we are told, improve, even as unneeded tests and therapies are avoided — a boon to patient, doctor and plan.

Some doctors are already superb listeners. Others may refuse to consider that their listening skills need improvement, engaging in the same form of denial as those who automatically assume that their patient panel is sicker than average when the HMO sends them them an unfavorable utilization report.

Imagine a forward-looking health plan providing good-listener classes for its physician panel. A small investment of plan money and physician time could boost patients' satisfaction with plan and provider. Not a bad deal, wouldn't you say?

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.