John A. Marcille

John A. Marcille

True, there are more uninsured now than there were seven years ago. True, health care alliances and employer mandates failed to materialize. True, no National Health Board was ever created to monitor the functioning of employer health alliances.

Yet, yet...

A caption under the photograph of President Clinton on this month's cover could easily read "Gottcha!" Much of what he and Mrs. Clinton tried to push through Congress in the Health Security Act has squeaked through states and the public sector, as our cover story by Contributing Editor Michael Levin-Epstein makes clear. The plan is being enacted minus the bureaucracy, but also minus the spirit of competition and universal coverage.

Those who decried the effort as just so much sound and fury may not have been too far off the mark. The sound and fury points to the debates that raged around the effort. But while Mrs. Clinton lost, parts of her proposal have a life of their own.

As Rep. John Cooksey of Louisiana says, Mrs. Clinton deserves credit for getting many serious issues into play. She may be as responsible as anyone for any movement on health care policy that is taking place.

She may, also, be responsible for the slow pace of change. Mrs. Clinton got burned, as they say, and her name and health reform are often joined as a pejorative.

America clearly doesn't want a government-imposed system.

Unless, of course, managed care's track record forces the issue. A recent report by the Institute of Medicine says that each year 50,000 to 70,000 adults are killed by diseases that could be prevented or mitigated by vaccines. Here's where managed care can really step in and, through disease management, make a difference.

It should be remembered that "HillaryCare" was killed by fear and that is an emotion that cuts both ways.

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.