John A. Marcille
MANAGED CARE January 1998. ©1998 Stezzi Communications

John A. Marcille

Managed Care has two main groups of readers: practicing physicians and health care plan executives. As you might imagine, crafting stories that will be of interest and use to both groups is quite a challenge.

Every month we reject proposals that are one-sided, inflammatory, self-serving and/or short-sighted. But don't for a minute think we are watering anything down. In this issue, for example, you'll find strong views on the place of physician practice management companies (the cover story, on page 19, and "Are PPMs Beauties ... or Are They Beasts?" on page 26), on the effects of the federal Mental Health Parity Act (Parity for Behavioral Health," page 33) and on the wants and concerns of the employers who pay the health care piper and who, increasingly, insist on calling the tune ("An Interview With Catherine Kunkel," page 41).

As I ease into the editor's chair that has been filled capably by Timothy S. Kelley, Patrick G. Mullen and Carroll S. Dowden, I plan no drastic changes. Managed Care will continue to print a diversity of features stories, news items and commentary. Each of us has a distinct personality and background, pet peeves and peculiarities. It would be vain and ridiculous for a writer or editor to claim objectivity. I do promise, however, that our staff will do its best to make Managed Care timely, fair and useful. And I know that what I learned in my earlier newspaper work, plus my service on this magazine and my work on related publications, will help me keep that promise.

We believe that all parties share — or should share — the common goal of providing high-quality health care, even if they may define and measure it differently. And we believe that mutual respect, coupled with vigorous debate, will help the health care establishment sort out its differences with a minimum of interference by legislators. We plan to contribute to that debate.

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.