John A. Marcille

John A. Marcille

Valedictories sound more or less the same. It's as if there exists some metaphysical blender into which nervous speakers pour the usual suspects — "stand on the edge of a new beginning," "with the foundation you've learned here," "as I gaze out upon your hopeful faces," "for everything there is a season" — add a little personal flavor, press "mix," and see what foams up. There may be slight variations in color and texture, but it's all foam just the same. Thinking about such speeches can make your eyes glaze over.

So when we here at Managed Care decided to look at the future, we set some rules: Try to avoid the word "millennium" and keep observations about where health care goes from here as concrete as possible. In short, stay with the game plan followed in each issue.

We asked prominent, thoughtful people in health care to discuss the future and — hopefully — their ruminations are as unlike valedictories as can be found. In fact, their essays are interesting because for the most part, they minimize generalities.

What about liability? Steve Wetzell of Minnesota's Buyers Health Care Action Group thinks the outcome of the Patients Bill of Rights debate may determine whether employers continue to offer health care benefits at all.

True care management? Peter Juhn, M.D., of Kaiser Permanente says without physician enthusiasm, it's hard to pull off.

Technology? The AAHP's Karen Ignagni says plans are finally in a position to help physicians provide effective population care, and this may help the industry mend its tarnished image.

Substance over style also triumphs in a peer-reviewed feature — also forward looking — that examines the economics of disease management. Peer-reviewed articles are now a regular part of this publication.

There's more — pages and pages more. So, please, enjoy this snapshot of what's next. An opportunity like this only comes around ... every month or so.

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.