Timothy Kelley
MANAGED CARE November 1997. ©1997 Stezzi Communications

Timothy Kelley

On a recent Tuesday, events seemed to be overtaking the magazine we were rushing into print. I was editing the interview with Paul Ellwood Jr., M.D., and its keynote was optimism. The inventor of the term "HMO" had told me he was newly hopeful about viable quality comparisons among health plans — and thus about the "managed competition" model he and Stanford University economist Alain Enthoven had envisioned for a new health care system. The triumph of optimism in the once-despondent makes great copy — especially near Thanksgiving. So why was the sky so inconsiderately falling on Wall Street?

I confess I haven't the financial smarts fully to comprehend how a company worth X on Friday can be worth less than half of X on the following Monday — without any major fires, explosions or embezzlements. But as for the journalistic cluckings that greeted the Humpty-Dumpty performance (from $68.75 to $25.88 a share) of Oxford Health Plans in Nasdaq trading Oct. 27, those I could have drafted myself. "Some economists have begun to question whether, over the longer term, health maintenance organizations can deliver on their promise of keeping health costs under control," said the New York Times. Chimed the Wall Street Journal: "The entire HMO industry is struggling with ... public concerns over whether managed care companies are denying needed care to patients to hold down costs."

I soon realized that, far from making our issue obsolete, the Oxford stock plunge and the comments it engendered (despite that company's special circumstances) actually made Dr. Ellwood's remarks more pertinent than ever. He is saying, after all, not that everything is rosy, but that pressures now facing the HMO industry will push it in the direction of true quality competition, increasing its reliance on primary care physicians.

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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.

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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.