Timothy Kelley

Timothy Kelley

Overconfidence is rarely the danger in monthly magazine publishing, but I keep D.H.'s letter taped to my wall to guard against it, just in case. D.H. is the Washington State physician who took the trouble to write us, "I find your publication singularly worthless and do not wish to ever receive it again." The note was dated April 1, and we naturally hoped the infinitive-splitting Dr. H. was only fooling, but the months since have failed to bring a follow-up note gloating, "Gotcha!"

Such is the human propensity for denial that we convinced ourselves that only one thing about our magazine could make D.H. that mad: our title. Some physicians simply cannot abide managed care, and don't want to see anything in the mailbox that bears its name. But it so happens that a recent independent readership survey gave Managed Care better notices than D.H. did. In fact, it gave us a pretty good claim to being the best-read magazine devoted to — you guessed it — managed care.

A year ago we launched a special edition with the cover article targeted to managed care organization executives. The recent survey results, we're happy to conclude, seem to bear out the wisdom of that initiative. But it didn't come without a price.

The mere fact that Managed Care serves HMO and preferred-provider organization administrators as well as contracting physicians disqualifies us from one particular approach to medical-business journalism. That approach cozies up to physician readers and presumes to anticipate their every harrumph: "Look what those so-and-sos are doing to you now!"

Frankly, we've never cared for that patronizing style anyway. We cherish our freedom to point to the warts in managed care — witness our discussion of gag rules a year before they became hot — and we'll continue to do so. But managed care is here to stay. So we also want to address affirmatively how doctors can thrive in the business of medicine, and we'll keep doing that, too. Even if it means we'll never be D.H.'s favorite read.

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.