John A. Marcille

John A. Marcille

The philosopher G.K. Chesterton, writing at the turn of the century (last century, not this one) said, "The whole difference between construction and creation is exactly this: A thing constructed can only be loved after it is constructed; but a thing created is loved before it exists."

Our cover story on IPAs seems to be about a system created by those who wanted to restore the healing touch that many perceived as having been siphoned off by managed care. Some would say that IPAs, more than HMOs, appear to be about love of medicine more than hatred of rising costs.

As author and contributing editor Karen L. Trespacz points out, the two systems need not be antagonistic. In fact, IPAs can help HMOs in so many ways: from jump-starting new plans, to improving compliance with health programs, to promoting better medical management.

Clichés are harmful not because they are wrong; they're harmful because they encourage lazy thinking. So think before you agree that all health care is indeed local. Then further accept that IPAs may be the best system for managing care locally.

It comes down to what works, what doesn't. No surprise there. That's always how it is in this magazine and this issue is no different. Read about how auto maker DaimlerChrysler applied this process in streamlining care for its employees and the health plans that serve them. Take a look at the problems — lack of historical data, ambiguous language — that can turn a risk-sharing contract sour. Our Q&A is with the head of the People's Medical Society — Charles B. Inlander — who doesn't pull punches discussing what he thinks makes sense.

Finally, there's a story about how physicians often attack colleagues in the press, tarnishing the public's view of the profession. Chesterton fielded this one as well: "The artistic temperament is a disease that afflicts amateurs."

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.