Timothy Kelley
MANAGED CARE March 1997. ©1997 MediMedia USA

Timothy Kelley

Editors have the damnedest preconceptions. When I was a reporter for my college newspaper in Chicago, I was sent to cover a demonstration at a hotel where President Lyndon Johnson was scheduled to speak. The editor was infatuated with the notion of LBJ "eluding" antiwar protesters to enter the hotel, so he rewrote my story's lead to characterize events that way. The trouble was, as my article went on to say, "the demonstrators left before the president arrived." Some "eluding."

This time, I plead guilty to being the editor with a pet notion. In conceiving this month's cover article (page 22), I was obsessed with two metaphors: the teacher who abandons the curriculum and teaches only the test, and the image of something "falling through the cracks" — in health care, for example, if all energies went to improving things that can be quantified.

Oddly, Contributing Editor Maria Kassberg and Senior Editor Paul Wynn hesitated to accept these metaphors in lieu of a coherent story assignment. They kept asking pesky questions: "Is our main purpose to suggest new quality indices that ought to be tracked?" (Not exactly, I said.) "Is it, on the other hand, to defend a view of medicine as partly an inscrutable art form?" (Again I demurred, mindful of what National Committee for Quality Assurance President Margaret O'Kane has to say about that view in our conversation with her.)

Finally I took refuge in a third metaphor. Our story would be "shaking the tree" in five areas of health care quality, I figured, and whatever fell out should be valuable. That idea may have been lame, but it did let me notice when an old friend tumbled out of the tree — a classic managed care goal called prevention.

Not just to save money but to provide truly high-quality care in heart disease, cancer, birth complications, asthma attacks and diabetic retinopathy, say the experts we consulted, some of the interventions most worthy of heightened efforts are those that help to prevent these conditions in the first place.

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.