John A. Marcille
MANAGED CARE August 1997. ©1997 Stezzi Communications

John A. Marcille

American global supremacy, following British global supremacy, is not the only reason that English is spoken around the world. It happens to be a tongue that, even without the grammatical elaborations of Latin, German and Russian, is able to convey detail and nuance. But many in health care seem to be doing their best to ruin that reputation.

Payor. What nitwit came up with this? What's wrong with payer, a spelling that is actually in my dictionary? Payor is creeping into new editions, because people are using it through (not thru) ignorance, but a dictionary only reports how people use words; it is not a guide to good usage.

Disease state management. I was gratified that Alan Hillman, M.D., (page 75) also considers this a term that may have meaning for speaker and listener, but not necessarily the same meaning. The same goes for plenty of other terms, including "quality," as you'll read in the cover story, starting on page 30.

Cap. Capitate is too long to say, huh? We can devise all sorts of wordy Latinate expressions to make us sound erudite, but capitate is too long? Sorry, but cap — from the same root as capitation (which before we got hold of it meant "collecting a head tax") — means a maximum, an upper limit. If I say I "capped" their reimbursement," two meanings are possible.

Reimburse. Physicians, though they are concerned with income, don't like to be perceived as interested. They are paid, but rarely reimbursed (paid back). Even "compensated" has that tinge of paying back. Please, let's not beat around the bush.

All of this pales next to adspeak. I heard from "a specialty teleservice bureau that provides interactive customer communications," which are "customized telemarketing and database management solutions for health care and pharmaceutical companies."

Life would be easier if we could just go out and buy solutions. I'll take a solution to mid-life crisis, please.

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.