John A. Marcille

John A. Marcille

Confrontation and cooperation: Both have their place. Senior editor Frank Diamond's cover story on the relationship between hospitals and health plans highlights the confrontational or competitive end of the spectrum.

In the aftermath of the Balanced Budget Act of 1997, Washington's inexpertly crafted milk-Medicare measure, the relationship between HMOs and hospitals has become downright stressful. Not so stressful as the HMO-physician relationship, mind you, but stressful nonetheless.

This story involves a familiar theme: escalating costs and dwindling financial resources. The answer, as far as HMOs are concerned, is to squeeze every penny of waste out of hospitals. The hospitals say the Balanced Budget Act has already taken care of that — and, by the way, could HMOs please keep physicians under tighter reins?

The market will most likely work out a solution to this problem eventually but, in the meantime, duck. Hospitals are beginning to challenge HMOs' denials of care more aggressively. Plans hold the leverage in this contest, but can they really afford to do battle with institutions that have such strong community ties?

If both sides are in fact inching toward war, then they do so with much reluctance, realizing that this is a confrontation that no one can win.

Competition seems to have become such a basic part of managed care, it's nice to be able to print an article on HMO cooperation. Regional cooperation and standardization of reporting forms, of credentialing, and of basic guidelines (such as immunization) can remove at least a little of the paperwork burden on physicians and actually improve data collection and analysis at the cooperating plans. Patient care seems to improve when these systems are instituted.

Also regarding cooperation, check out the article describing a pharmacist-run anticoagulation clinic that both physicians and patients seem to like.

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.