Timothy Kelley
MANAGED CARE May 1997. ©1997 Stezzi Communications

Timothy Kelley

They tell you you'll never forget high school and they promise glories for the "golden years," their very fulsomeness a hint that adolescence and old age can be two of life's most horrific chapters. But they don't tell you that in your mid-forties you will suddenly become unable to see any object that is either (a) very close to you or (b) very far from you, unless you constantly switch eyeglasses — and sometimes not even then.

Having reached this era and identified this debility, however, I made it a point at last month's National Managed Health Care Congress to sit brazenly in the front at each session I attended. That way, I figured, my eyes would be a safe, middling distance from the slides and I'd have a fair shot at deciphering them.

No way. Speaker after speaker, hurrying through complex materials, paused to apologize for absurdly crammed visuals with tiny type that would have been unreadable from the front row even if the projector operators had been acquainted with the concept of focus, which often they were not. In one case, even a cartoon slide — something evidently included for its very accessibility as a tension breaker — appeared to my admittedly imperfect eyes as an undifferentiated bluish haze.

"It's in your handouts," of course, is the ubiquitous excuse. But sometimes it isn't. And even when it is, how many of us, having taken four days off to attend a conference, can devote much further time to detailed study of the conference materials?

I don't mean to single out NMHCC for abuse. Actually, that meeting provided an impressive array of well-informed speakers with clear presentations. (One of them, Peter Kongstvedt, M.D., of Ernst & Young, was kind enough to sit down with me for a wide-ranging interview.) But it seems to me that managed care's complexity cries out for coherent explanation, and that while most speakers chosen for its various conferences explain that complexity well, the simple matter of clarity in visual aids apparently defeats many of them.

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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.