John A. Marcille

John A. Marcille

Physicians are not only second-guessed by health plans that disagree with their decisions, but are bombarded with step-by-step rules for treating disease.

Highly trained and experienced, they should be excused if they resent it. Most probably don't, however, because advisory guidelines are important tools. This month's cover story finds wide agreement among physicians, as well as plans, that advances in medical science are unacceptably slow to trickle down to the trenches. Even assuming the profit motive, it is in the interest of managed care plans to promote the most effective medicine, and one way that many do it is by disseminating guidelines and other clinical information.

We expected to find examples both of positive and negative reinforcement, but we could find no plans that actually admitted to strong-arming doctors. Good. Plans should not be forcing physicians, but they can do a service to all the stakeholders — themselves, physicians, patients, employers — by encouraging physicians and giving them easy access to information.

One consortium of heath plans in Texas is pointing the way by agreeing on clinical guidelines, starting with diabetes. I like this idea because physicians would have only one guideline to consult, even if treating patients from a dozen health plans. And it also allows for local physician input — highly desirable.

That's one way to promote up-to-date practices. Another is to help physicians acquire computers and software that will allow them to easily and quickly consult guidelines and other current medical literature. Here, the fragmented managed care system works against itself, for what plan wants to subsidize a purchase that will aid its competitors? But an influential organization such as the American Association of Health Plans might, for example, marshal its members to pay a small amount to every practice — based on size of patient panel — for hardware/software purchases that could facilitate clinical, as well as administrative, efficiency. It's worth considering.

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.