LOOKING FORWARD

In a few weeks, the calendar will tick over and, if we've solved our Y2K problems, we'll be seeing a calendar year none of whose digits will be the same as this year. It will look new (even though we know it's really the last year of the second millennium) and may invigorate us. A little emotional support couldn't hurt a health care system that has been buffeted by winds from all directions for years.

We could say that we're on the cusp of dramatic new developments in health care, but people have been saying that for a decade, and there's been no revolution yet. Evolution, however, is indisputable: The '90s have seen significant advances in understanding many diseases, and if treatment advances haven't kept pace, they've done pretty well. The health care delivery system has evolved in ways few foresaw a decade ago. The rise of HMOs to a position of overwhelming influence on the delivery of care surprised a lot of patients and physicians, and lately the increasingly successful counterattack of the "unmanagers" who brought us point-of-service plans, mandated minimum hospital stays and, now, a patients bill of rights, has become a thorn in the side of health plans that pretty much had carte blanche.

The calendar will change dramatically, but there will be no apocalyptic change in health care. Evolution, maybe even progress, will continue.

But what changes? We asked influential participants in the health care system what they saw as developments and issues that would dominate the first half of the '00s (though we didn't ask them to pronounce '00s!). Each speaks from his own field of expertise, and if some show a little self-interest, well, that's part of the equation. They represent distinct constituencies (health plans, physicians, analysts and academics, disease management purchasers, and employers, for example), and all see significant movement within their areas of expertise over the next few years.

We'd like to share their visions and expectations with you. We hope you'll find them as provocative as we do.

Articles in the Looking Forward Series:

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.