John A. Marcille

John A. Marcille

I try to be receptive to new ideas. I really do. After several years covering managed care, I've watched quite a few run up the flagpole, only to see them unceremoniously lowered for lack of salutes.

Sometimes I buy in. Later I'm embarrassed because I didn't think the issue through, or mystified that others didn't share my interest and approval. Sneer if you want, but President Clinton's health care reform plan had strong points: competition was promoted, enrollees' (not employers') choice was ensured, fee-for-service was even given a fighting chance. Yes, the plan was a boondoggle, but was the nation well served by the coalition of special interests that dismissed it instead of fixing it?

This month I'm willing to buy into the idea that greater management of workers' comp care (see our cover story, starting on page 31) will hold down disability insurance payouts and return workers to the job quickly. I'm also intrigued by the idea that some workers' comp principles could be applied to group health. But it bothers me that so many of the changes we see in health care are being made in the interests of employers, and only incidentally of enrollees.

It wasn't so long ago that the "primary care gatekeeper" model, which made sense to employers with ballooning health care costs, was new to many physicians. They quickly learned that they not only were required to be more strict about whether to refer than they had been under indemnity financing, but that their income was inversely related to their frequency of referral. But as we see on page 105 of this issue, the primary care physician isn't Superman, however close he may be. Another good idea gone slightly awry in the implementation.

As we evaluate new management techniques in the rush for competitive advantage, we must remember that the enrollee, sometimes quaintly known as the worker or the patient, should be more than a pawn on the corporate chessboard.

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.