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

John A. Marcille

So much happens at each National Managed Health Care Congress that it is impossible to distill the experience. Thousands of physicians, pharmacists and other professionals, plus hundreds of vendors, converged on Atlanta last month. Still, some things stand out.

At the the policy level, there was concern for structural and political issues, the former exemplified by Harvard Professor Regina Herzlinger's keynote talk on market-driven health care. As it happens, Senior Contributing Editor Patrick Mullen interviewed her just a week before the conference, and you can read the transcript, starting on page 40.

Former New York Gov. Mario Cuomo, a Democrat, in a debate with a potential GOP presidential candidate, former U.S. Rep. Jack Kemp, also of New York, warned against trusting entrepreneurs to structure a health care system that will ensure availability of care for the growing ranks of the uninsured, though he did argue, "If you can do it privately, that's the first choice." Kemp spoke for tax credits or vouchers for the unemployed uninsured and tax deductions for the employed uninsured (Cuomo: deductions are wrong because they favor the wealthy)."There should be a direct subsidy to the poor," Kemp said, observing, "Even my party has gone to extremes" in addressing the problem. Notably, they agreed that definitive action on this issue and most of the many managed care regulations proposed in Washington is unlikely this year.

So much for policy. At the nitty-gritty level, there was a lot of attention to legal liability — providers have it; health plans may have to confront it — as well as disease management successes (finally being documented) and the newer kinds of managed care organizations, such as provider-sponsored organizations and integrated systems. The ideas batted around, no less than the web of contacts and alliances made by the thousands of participants, will surely affect the development of health care.

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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.