John A. Marcille

John A. Marcille

It's a problem, all right. Patients aren't just complaining any more. As forgotten players in what all too often seems to be a tug of war in many directions, patients — the ultimate consumers of health care, are making their presence felt.

A few years ago they might simply have groused about being denied a referral or being booted from the hospital sooner than they and their physicians thought proper, but more and more they are exerting their power in the courts, with their employers and, most publicly, with Congress and state legislators. Senior Editor Frank Diamond covers these and other aspects of this sea of change in our cover story.

Managed care is partly responsible for this turn of events. It had a mandate: Control costs. It did some obvious stuff, like utilization review and generic substitution. In most cases this didn't result in harm, and some had benefit beyond cost control (some unneeded procedures weren't performed, for example, sparing patients the dangers associated with surgery and/or hospital stays). But, insulated because their employers paid most of premiums, patients only noticed the clinical controls.

Americans across the board are being forced to be self-reliant. Pensions have given way to 401(k) and other self-directed investment plans; welfare recipients are cut from the rolls after a period; few now believe their jobs are permanent.

Health benefits and costs are broad civic issues. Though patients deserve more control over their care and coverage, uncontrolled access to specialists would raise costs needlessly when the more conservative approach — ensuring access, at a price, to a plan that features uncontrolled access — is just as fair to the individual, and better for society. Lawyers, specialists, and others who say they are on patients' side stand to benefit most from the lavish spending managed care resists. Legislatively, consumers and these "allies" quickly have accumulated a great deal of power. May they use it wisely.

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.