John A. Marcille

John A. Marcille

Senior Editor Mike Dalzell, author of this month's cover story on the degree to which so-called "report cards" are being taken seriously, has a daughter in primary school. So does Frank Diamond, also a senior editor. They know about report cards.

"When my six-year-old daughter recently brought home her first real report card," Frank told me, "I was ordered by someone close to both of us — you'll never guess who — to make a fuss. Busy and distracted fathers sometimes need such encouragement to realize that while a 'VG' in social skills may look like two twenty-sixths of alphabet soup to us, it's one of the most important things in the world to a first grader."

Maybe more employers of the nation need such encouragement to review the "report cards" issued to health plans. As Mike's story illustrates, only 6 percent of employers use HEDIS data, the gold standard of quality-of-care measurement. This apathy bodes ill — not only for employers and, down the line, their employees — but for those plans that are trying their best to do right as the National Committee for Quality Assurance gives them the light to see the right. (Apologies to Lincoln.)

Any good mother will tell you about the power of positive reinforcement. Any good coach will tell you about fear of failure. These lessons are as basic as the ABCs. Neither of these motivations can work as well as it should if no one is watching.

As the article so ably points out, the next time someone rails about lack of concern about quality, the anger might be best directed toward employers. Everybody needs encouragement.

Just ask any 6-year-old. Or physician. Everybody, it seems, wants to know how "good" his own doctor is. This may be why report cards focusing on them do get attention. Maybe too much attention, some physicians fear, in that it puts them right back where they don't want to be: foot soldiers in a battle whose shots are being called from corporate offices.

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.