Peter Lee, J.D.

Peter Lee, J.D.

Better-informed patients need not be a bane to other players in the health care industry. Interaction doesn't have to be adversarial and should include the historical "have-nots."

Four themes will continue to grow in importance as the shift to consumer and patient empowerment continues into the 21st century. Consumers will want more and better information so they can participate in decisions about their health care. Consumers need to be more directly engaged in the challenge of keeping medical costs in check. The calls for accountability will extend beyond health plans to individual doctors. And, there will be increased recognition of the necessity of addressing both the needs of the health consumer "haves" and the health consumer "have-nots."

Informed consumers

Patients are walking into doctors' offices with material from the Internet — this trend will grow in the years to come. Too often doctors roll their eyes when this happens and think, "Here we go again." Other doctors say, "Great! Let's see what you've got there and let's talk about it."

These situations should be seen as incredibly important opportunities for doctor-patient dialogue. Consumers will be more and more attentive to those they can trust.

Accountability issues

The push for accountability will go beyond the current array of legislative initiatives and consumers will increasingly ask whether they are getting quality health care. Patients will ask tough questions about the quality of their provider — not just of their health plans (they're already moving beyond that) — but also of their individual doctors and the particular care being recommended. They will ask: "Is this the right care for me and is a person with the right qualifications recommending it?" That's going to be an increasing source of friction.

Who pays?

Consumers are becoming more sophisticated, looking at when they pay as opposed to when their insurer pays, what's out-of-pocket, what's not out-of-pocket. But beyond understanding payment terms, consumers need to be better engaged in the coverage choices that may limit benefits.

Much of consumer concern about managed care has focused on the questions, "Who's denying what, and what's the basis of that denial?" They have wondered if a qualified physician is denying care because it truly isn't medically necessary or an accountant is denying care as part of a health plan's cost-cutting measure.


In the past five years, the so-called consumer-protection debate has included virtually no discussion of the issues of the health care have-nots — those who are uninsured, are underinsured, or have limited ability to understand the growing array of report cards (in the rare case where these individuals have a choice to make). The high rate of those without health insurance is a national embarrassment and represents thousands upon thousands of individual tragedies.

Hopefully we will get to some form of universal coverage through a variety of means. Beyond expanding coverage, a major challenge is how to respond, on the one hand, to the educated drivers of the health care system while not leaving behind patients who are less educated and assertive.

Peter Lee, J.D., is the executive director of the Center for Health Care Rights in Los Angeles.

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.