Timothy Kelley
MANAGED CARE January 1997. ©1997 Stezzi Communications

Timothy Kelley

The verb "to satisfy," in its various forms, is subject to a host of applications — some of them X-rated, of course, and some even sarcastic. I recall laughing at a line in the final episode of "The Dick Van Dyke Show" more than 30 years ago, in which sitcom regulars enacted a "High Noon" western spoof that was actually a dream Van Dyke's character was having in the dentist's chair. Hero Rob Petrie had had to face villain "Bad Brady" alone because none of the cowboy bystanders would join a posse. "And now he may die!" the hero's wife scolded the bystanders after the showdown. "I hope you're satisfied!"

The cowboys, having saved their skins, stood with folded arms and replied in a chorus of deadpan casualness: "Yeah, I think we're pretty well satisfied."

Our cover story this month, which begins on page 23, is about a health plan that excels at keeping its members satisfied. The meaning here isn't sarcastic, but it is distinct. It is different, for example, from objective indices of medical outcomes or patients' health. But member satisfaction itself can do much to affect the success of a health plan — or a physician practice.

We conceived this article before we knew that our choice for discussion would be Capital District Physicians' Health Plan in Albany, N.Y. Indeed, we hold no special brief for that HMO or any other. But given the temper of the times we weren't surprised to learn two things. One was that despite its notable success in one important area, this health plan, like all others, still faces challenges. It's ironic, for example, that this champ of an organization did not win accreditation from the National Committee for Quality Assurance on the first try — reportedly because of missing documentation rather than quality lapses. The second nonsurprise was that the plan seems to have managed so far to operate with respect for its doctors rather than arrogant manipulation of them. If there is one ticket to success this magazine would humbly recommend, that would be it.

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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.