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

John A. Marcille

Formularies are an established part of the managed care arsenal now, but they are still not universally accepted. Even now, not all HMOs, for example, have formularies, and many formularies are still advisory.

In our cover story, beginning on page 23, Contributing Editor Jean Lawrence writes about the pressures on health plans to control pharmaceutical costs and the pressures on physicians to conform to the corporate line. What made me hopeful was her discussion of various ways in which physicians are moving toward better compliance without more hassle and pain, from just plain philosophical acceptance of the formulary system (with the opportunity to override for medical necessity) to the introduction of simple and sophisticated technological aids.

This incrementalism to me is part of the story of managed care at its best — identifying a cost-control or health care need and finding ways to address it without doing harm.

The term "incremental" pops up on this month's Q&A feature, an interview with Ron Pollack of Families USA. Pollack addresses the complaint that the Clinton administration is engaged in an incremental (read "back door") policy of instituting its failed national health care reform. Pollack is not quite a health care insider, but his views on health policy reflect and distill many of the concerns and resentments that purchasers and patients share.

Speaking of patients, as we should never fail to do, if you turn to page 31, you'll find psychologist Mark Hochhauser's unconventional look at HMO report cards. Mark doesn't address their importance to employers, unions, governments and other bulk purchasers of health care, but he argues, and I think persuasively, that they aren't much help for many consumers.

Acceptance of formularies. Improvement of report cards. These are good increments that can service society, medicine and business well.

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.