John A. Marcille

John A. Marcille

Paul Ellwood, M.D., who is generally recognized as the father of managed care as we know it, envisioned a world of health care delivery that featured HMOs with exclusive teams of physicians. The HMOs — and, indirectly, their physicians — would compete less on price than on quality of care and the ability to achieve superior outcomes.

We are a long way from Ellwood's vision of managed care. Not that Ellwood's is necessarily the best way that high-quality health care could be delivered. But the fallout from the mutation of his conception has has left a lot of plans, doctors and patients on the brink of revolt.

Or has it?

Look beyond the managed care backlash, and you'll see a quiet maturation taking place in the relationship between physicians and health plans. The two sides are getting together — sometimes out of necessity, sometimes out of genuine mutual desire. But at least they're acknowledging one another.

Our cover story — "Truce!" — examines this phenomenon. To be certain, battles will still be fought. But as physicians are beginning to accept managed care as the cornerstone of medical delivery in this country, payers are understanding that doctors are the core of the system. This is forcing an alignment of values. At the same time, an effort to link managed care companies with academic medical institutions — immersing tomorrow's physicians in the practices of managed care — is bearing fruit.

More signs of a truce: Health plans have a responsibility to use their data-mining capabilities to help physicians improve quality of care, and many are becoming sophisticated at doing that. As for physicians, before they can embrace managed care, they have to understand it. And more and more doctors are returning to the classroom to gain skills they need to participate in it. We cover both of these developments in this issue.

These occurrences are driven by a common goal: the provision of efficient, high-quality medical 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.