John A. Marcille

John A. Marcille

It happens over and over. Somebody has a clever idea for a system that will promote better care and/or lower cost. The health care system as a whole embraces the system, uses it for a while and then finds problems that were not envisioned, or were minimized.

Global capitation encourages primary care doctors to tackle specialty care for which they are not trained. Preauthorization wastes their valuable time and irritates doctors in other ways. Genetic screening may put patients at risk for losing affordable health care coverage.

So it goes. Contributing Editor Bob Carlson's cover story on the gradual demise of a number of financial incentives offered to physicians is another case. The theory here is that incentives to hold down costs may also be incentives to limit care. There is some truth to that, and so courts are stepping in to protect the patient, who too often is a pawn in a game played by employer, health plan, and provider. Sometimes the problems seem larger than they really are.

Many medical groups, in fact, are not happy with this trend. They've been able to balance budgets with care, and do the right thing by everyone, and now they — and society, which will pay more for less — will suffer.

Still, new techniques will be advanced and some of them will work, as have the concepts of centers of excellence and treatment protocols. What's so attractive about this kind of approach is that quality — which everyone wants — comes first, and cost management follows when the correct thing is done at the correct time. The same will be true when (hopefully) we make some progress in suppressing the enormous number of medical errors that injure patients and jack up cost.

The health care system is more than just health care companies. We're all participants; we all have rights and power. Replacing one tool with another (we like carrots more than sticks) is to be expected and embraced.

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.