Timothy Kelley
Managing Editor's Memo

Timothy Kelley

We may never know the identity of the public relations genius who decided that "downsizing," itself euphemistic, was too blunt a word to describe corporate layoffs. Presumably to assuage the readers of news releases and annual reports, he or she coined the replacement term "right-sizing," so that victims of the process might hear the sweet justice of their joblessness in the very verb that unemploys them.

No matter; physicians don't need the services of that same euphemizer to fix the problem with the "gatekeeper" image — its suggestion that people may sometimes find the gate shut. What primary care physicians need is a straightforward vocabulary for explaining to patients how managed care works, and the fact that, as Ethics columnist John La Puma, M.D., writes, "We too have to live within the rules."

In Managed Care's pages last June, Alan Hillman, M.D., of the University of Pennsylvania's Leonard Davis Institute of Health Economics called for physicians to explain to patients the financial incentives under which they work. We're happy to note that others have since echoed Hillman's call — and his denunciation of the so-called "gag" rules by which some plans limit physicians' ability to speak freely to patients. In a welcome step, the large HMO U.S. Healthcare (a future Aetna unit, it now appears) announced that it was replacing its analogous contract clause with one that requires secrecy only for "competitively sensitive information and confidential patient records."

How to be appropriately candid with patients about financial incentives — without scaring them or making them doubt that their health remains the top priority in care — is just one of the challenges primary care doctors face in a system whose designation remains stubbornly associated with the gate symbol you see on this month's cover. In this issue, we examine the gatekeeper system and some of the ways it is being revised and questioned. We hope you find the article useful.

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.