MANAGED CARE March 1998. ©1998 Stezzi Communications
Washington Initiatives

The American Academy of Family Physicians likes the Clinton administration's consumer bill of rights proposal, especially its call for choice of primary care doctors. But it doesn't like the provisions dealing with increased access to specialists, treatment and medical care. AAFP likes the president's plan to tax cigarettes and ban tobacco company advertising that appeals to youngsters. But it doesn't like the president's attempt to limit the rights of smokers who seek to be compensated for tobacco-related illnesses. And the 85,000-member organization likes the administration's initiative to increase funding for biomedical research. But the physicians don't like its meager funding of primary care medical research.

In short, AAFP's reaction to the administration's health care plan is much the same as many other interest groups: There's definitely something to get behind, not perfect, but, compared to the ill-fated 1994 health care reform initiative, it's a whole lot better.

The buzz here is, because the administration — unlike four years ago — is trying to achieve consensus first, there's a chance that at least some major initiatives may actually see the light of day.

AAFP is clearly supportive of one major program outlined in Clinton's State of the Union Address and fiscal 1999 budget: expansion of Medicare. Neil Brooks, M.D., president of AAFP, says family physicians "worked with Congress and the administration last year to help insure poor children. Now we support this year's goal of providing affordable care to near-retirees."

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.