John A. Marcille

John A. Marcille

Religious philosophers have often begun their discourses with a discussion of what's wrong with the world. The "bad" is a fact as plain as potatoes; what's "good" can be harder to pin down.

Novelists bemoan the difficulty of creating "good" characters who are interesting. Fascinating villains abound.

But in the business of health care, the focus is on the good, not the bad. Experts say finding good plans is easier than finding consistently bad ones and, anyhow, "Just how do you define bad plans?" and "Plans could be good at some things and bad at others" and....

Do these reactions point to a question flawed by oversimplification or do they point to an industry hampered by an unwillingness to police itself?

Our cover story looks at many issues related to identifying and dealing with health plans that miss the mark. I am heartened by some of the observations we report. But, apparently out of professionalism and perhaps some fear of retribution, most of the experts we consulted pulled their punches.

We are encouraged that there are so many pressures for quality in today's environment, but discouraged that physicians and small (and some not-so-small) employers are basically ignoring indicators of health plan quality in favor of cost and income considerations.

A pessimist would say that bad plans don't die, but live on, incorporated into another organization. But that's like saying a chicken doesn't die before you eat it. Its protein is incorporated into your body, but all the instructions for using it are yours, not the chicken's. In the present climate of corporate consolidation, recycling inefficient plans with poor processes for clinical improvement is one realistic and effective way that the market is confronting the issue.

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.