Timothy Kelley

Let's say I have an hour to kill, and my alternatives are enjoying a cheese-laden pizza while reading, say, that wonderful David McCullough biography of Harry Truman or heading down the road to my health club for 60 sweaty minutes of huffing and puffing in the company of guys with telephone-pole arms who noticeably snort when they have to set the whatchamacallit back from my 20 pounds to their 150.

I'm no masochist, and I know mortality isn't mutable in the long run anyway; the mozzarella wins by a country mile. But it could be argued — a bit simplistically, of course — that American health care's ultimate challenge is to induce me to wait till bedtime for Harry, and instead to endure the ministrations of those oh-so-friendly health-club helpers who I suspect are dying, underneath their salesmanship smiles, to act like my old shaming gym teachers.

It happens that I do become eligible for a partial rebate on my health club membership fee from my HMO if I do something-or-other — jump through hoops, I think. But with me feeling just fine, thank you, and my heart attack not scheduled until 2014, thousands of pizzas from now, can anyone really influence my behavior in my own long-term interests when their only ally is my conscience, which has a campaign record approximating Tom Dewey's?

There is, of course, big money to be made and great good to be done in helping me limit my pizza-parlor hours between now and 2014. In a way, it's the whole point of managed care. But my HMO's exertions in the matter will naturally be limited by its own stake in me, and our affiliation may not make it past next Dec. 1, when my employer must decide whether or not to renew, to say nothing of 2014.

Managed Care's cover article, on page 30, tackles this bedeviling contradiction at managed care's heart. And on page 53, on this topic and others, we let our readers "give 'em hell."

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.