John A. Marcille

John A. Marcille

What would this country be if we didn't have something to complain about? After all, America was born out of a difference of opinion, so it stands to reason that finding negativity in something and beating it to death has become something of a national sport.

Just look at the way the managed care industry gets slapped around like a hockey puck by the popular press and opportunistic politicians. Yes, the system has its faults — many of them. But it wasn't long ago that the same media fawned over those same politicians who decried runaway health care costs and pitied Americans who shelled a lot more out of pocket for their care than they do now. Those days seem forgotten.

So it was something of a pleasant surprise when we learned that direct-to-consumer advertising of prescription drugs — a favorite punching bag of the managed care industry — actually has a positive side for managed care companies and physicians. It's not necessarily the "educational" aspect of some ads, though the handful of those that do motivate people to see physicians for unknown or long-neglected conditions is a plus for everyone. No, what's particularly refreshing is that DTC advertising presents health plans and physicians with a few little-talked-about opportunities to mesh objectives with pharmaceutical companies in the name of improving outcomes. Senior Editor Mike Dalzell explains in his cover story.

Of course, not all DTC advertising is public-spirited. One health plan executive we spoke with put it this way: "To mindlessly drive unmitigated demand for drugs makes about as much sense as a two-headed man. What are we doing here?"

He's right, and yet that presents health plans with another opportunity: to help consumers distinguish need from want — i.e., restore consumerism in health care. It won't happen as long as people are shielded from the cost of care. With education, patients who have become accustomed to "near-free" pharmaceutical therapy might be more judicious in their resource use.

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.