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

John A. Marcille

A lot can happen in a short time. As I write this, President Clinton has just delivered his State of the Union address. A White House summary of his health care proposals is encouraging: putting the strongarm on tobacco companies to shield youngsters from being recruited into the ranks of smokers, passing a managed care consumer's "bill of rights" and boosting the National Institutes of Health budget for biomedical research $1.15 billion this year alone.

Who would have thought, four years ago, that cigarette manufacturers would be so clearly on the defensive, that state and federal government, so typically beholden to big contributors, would be so activist?

Who would have thought, four years ago, after the "managed competition" fiasco, that Clinton would be re-elected so easily? Or that he would now be waist-deep in a sex-and-subornation scandal?

Writing on deadline two weeks before we mail this issue, and knowing that a lot can happen in a short time, I wonder whether the president will be cleared dramatically or damned conclusively before we publish. Last month, when we sent out the January issue with its cover story on physician practice management companies, the MedPartners/PhyCor deal that we mentioned prominently broke apart as the presses were rolling.

In the '90s, a lot has happened to change the financing and delivery of health care in a short time, and just as in politics, it doesn't do to apply much certitude when looking very far into the future. But to fail to look, that's even more foolish.

When I look, I see continued government activism in reaction to managed care's failure to effectively police and promote itself. If it could do both, consumers would be reassured, the conservative Congress would back off and physicians and plans could get down to business — together. A lot can happen in a short time.

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.