Timothy Kelley

Usually it ill befits a magazine to take issue with its own past issues. But today I might rethink the opening line of the State Initiatives column in the May Managed Care. That column began, "The anti-managed care drive continues at the state level," then went on to describe legislative efforts in various states to assure that treatment for conditions with symptoms meeting a prudent layman's definition of "emergency" would be covered by health plans — even if, happily, the patient's condition as diagnosed by a physician turned out not to merit retroactively the designation of a true emergency.

Are such laws "anti-managed care?" If they are, maybe managed care will be rescued by its enemies from the opprobrium courted for it by its so-called friends. Now that I think of it, if I wanted to discredit a system of health care financing and delivery, I'd have it provide a steady diet of the double-cross described by emergency physician Gregory Henry on page 34 — his plight, that is, when that possible-MI patient he's examining in the middle of the night had better be having a heart attack, because if it's only indigestion the HMO will stiff him. And the patient, until he's examined, truly does not know.

What else would I do if I wanted to invite first legislative tinkering at the edges, then perhaps a government takeover of my industry? Well, I'd send all new mothers roaring homeward within hours of giving birth, never mind the medical particulars, and I'd threaten physicians with the loss of their livelihood if they told patients the full truth about their own medical options or the way their doctors are paid. (To read about "gag" rules see pages 19 and 37.) I'd impose stingy limits on care and penalize physicians who deviated from them. But if these limits led to tragedy I'd make sure it was the doctor, not I, who landed in court (see pages 21 and 37). Finally I'd salt the wound by paying myself a million bucks (see page 20).

Isn't it lucky managed care isn't managed by its foes?

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.