Timothy Kelley

Timothy Kelley

She was quite tactful about it, all things considered. Having prepared our cover article on interpreting recent surveys about managed care, health care opinion specialist Karen Donelan, Sc.D., of the Harvard School of Public Health had just seen for the first time the "fax-back" survey we're asking Managed Care's readers to complete. "Could you just indicate somewhere that I wasn't responsible for preparing that?" she asked in commendably gentle tones.

Our survey, you see, breaks some of the rules Donelan explains in her sidebar article, "How To Do a Patient Satisfaction Survey." Question 5, for instance, asks readers' views on the statement that, "With all its imperfections, managed care is preferable to full reliance on medical savings accounts, which could encourage people to neglect their health, or a government-run system, which could create a huge new bureaucracy." Replete with assumptions, that question is a survey professional's nightmare. What if one doesn't agree that managed care is imperfect, or that relying on medical savings accounts could encourage neglect, or even (it's possible) that a government-run system would promote a new bureaucracy?

No matter. We don't claim ours is a scientific sample. We're only trying to tease out some of the ambiguities in a subject that is rife with them. Besides, everybody who's anybody does a survey these days. A credit-card company sponsors a poll that finds (you'll never guess) that patients would like to be able to pay doctors with plastic. Beyond our cover article, pages 10, 14, 15 and 42 of this issue mention surveys of various kinds — we didn't plan it that way; that's just how ubiquitous opinion sampling has become. And it has bottom-line importance, too. As author Donelan points out, "Nowadays, physicians can find the tables turned on them. Once it was 'nine out of 10 doctors recommend'; today doctors may have their payments adjusted because one out of five patients didn't recommend them."

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.