John A. Marcille

John A. Marcille

What goes around comes around." Those of us not of vindictive temperament hope the adage applies to good things as well as bad. Perhaps that's the reason physicians seem to warm to the idea of a health care system in which patients can purchase their own insurance with the help of "defined contributions" supplied by employers.

Nancy M. Dickey, M.D., president of the American Medical Association, was one of many experts who spoke to Senior Editor Frank Diamond for our cover story on the "individual option." The AMA is pushing the plan, saying it restores freedom of choice to patients. Others quickly point out that it would put doctors back in the driver's seat (understandably, the AMA doesn't stress that), citing history in saying that that would be bad for health care: Fee-based medicine led to rising costs led to backlash led to managed care led to....

Would doctors, in fact, bond with patients as in the good old days? Would patients be inclined to favor doctors who overprescribe and overtest? How would you guarantee that employees actually spend defined contributions on health care and not on weekend getaways? How could individuals afford premiums that employers now buy at group rates? Where would all this leave HMOs?

Perhaps the most important question of all: Isn't this all very premature? We're still waiting to find out how medical savings accounts will fare.

Yet, how quickly things can change in health care. How quickly things can change, period. It wasn't so long ago that the 800-pound gorilla stalking our dream of a brighter future, the budget deficit, seemed to be parked permanently in our living rooms. That was due, partly, to an ever-burgeoning defense budget needed to keep missiles trained at an "Evil Empire."

Well, guess what? It's 10 years later and patients are asking what plan you're with, so they can join it. That's not so far-fetched, is it?

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.