John A. Marcille

John A. Marcille

It could be argued that the history of the United States is the history of checks and balances playing out against the backdrop of current events. There are times when a strong executive takes the reins: the Civil War, the Depression. At other moments, the legislature calls the shots: the GOP's recent "Contract With America." At times the courts, somewhat insulated from electoral concerns, go where other branches fear to grow: the beginning of the civil rights movement, for instance.

Senior Editor Frank Diamond's cover story on HMO liability touches on how these players try to harmonize with the chorus of public opinion demanding more HMO accountability. The courts seem to be stumbling at the fore of a muddled charge as Congress and the president debate whether patients should be allowed to sue employer-sponsored plans for denial-of-coverage decisions.

Meanwhile, HMOs have been dragged to the position, "Come to think of it, maybe external-review processes aren't all that terrible." Put simply, solid external-review processes — and no more, for now — answer public demand for plan accountability.

The tort system will create a lottery where only a few win and everybody else -- including patients and physicians — loses. No group knows this better than doctors, who needed statutory relief to cap malpractice awards in the 1980s.

Congress — not states — needs to install uniform external-review processes. While we applaud the AAHP's call that members do this voluntarily, this is one instance where national administrative standards will guarantee that Plan X plays by the same rules as Plan Y, and that neither can be outdone because Plan Z hires better lawyers or a friendlier review board.

In a few years, we'll look at this issue again. If the national external review process is seen as ineffectual, then legislators have a right — are, in fact, honor-bound — to extend liability to HMOs. We don't believe that will happen. HMOs will find a way to make external review work.

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.