John A. Marcille

John A. Marcille

Every state in the country is responding to the managed care backlash. From Bismarck to Baton Rouge, aspiring state senators are lapping it up, saving their best populist oration for that big, bad — and anonymous — creature, managed care. In good times, easy targets are elusive and like gold.

Preferred-provider organizations had better define themselves or run for cover. As described in this month's cover story, attention is about to land on PPOs. Anything that counts 100 million in its ranks can't go unnoticed for long. PPOs have a point in arguing that because most of them are discounted fee-for-service shops, they don't warrant the scrutiny HMOs get.

But a system that truly coordinates a patient's care (reducing unnecessary costs along the way) is a good thing. Abuses by some HMOs have given managed care a bad name, but PPOs have an opportunity to restore that image. If the fragmented entities that compose each PPO can set aside proprietary concerns, develop a common infrastructure, establish baseline health status for enrollees, and then monitor their care, PPOs have an opportunity to be a "quality leader" in managed care. This is larger than any single PPO; it may take an arm of government, such as the Agency for Health Care Policy and Research, to define standards and maintain a national database.

This is in PPOs' best interest — not just for regulatory prophylaxis, but also to help them survive the next economic downturn. More and more, employers are placing health care costs back on users. As Robert Trinka, of McKenna & Associates, told Senior Editor Mike Dalzell for this story, "The basic driver of all this stuff," meaning the state of the market, "is money and employers' willingness to pay." The notion of choice has proven too powerful to yank back from employees, but when benefit costs finally reassert themselves, workers who want the choices their PPOs give them will to have to fund it themselves. PPOs that can find efficiencies through higher-quality operations — not deeper discounts — have the best chance to flourish.

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.