John A. Marcille

John A. Marcille

In the mid-1980s, when Senior Editor Frank Diamond was working for a newspaper, he wrote a profile of a local caricaturist. As part of the interview, the subject rendered an outsized version in ink of Frank. The picture shows the cub reporter sporting a huge smile, pencil tucked behind his ear, running toward a typewriter. Frank thanked the man. He didn't point out that he used a computer and, in fact, had never used a typewriter in his writing career.

As a former newspaperman who's actually old enough to remember banging out stories on Smith-Coronas, I have to smile. Words and symbols we use often outlive their usefulness in the real world. When's the last time you "dialed" a phone number?

This brings us to our cover. You will be forgiven if you were somewhat taken aback by the rendering of the nurse's cap. When was the last time you saw that? And yet, as a symbol, it resonates.

There's also a reflector. We all know that means physicians. Those with a critical bent may point out that the cover art misses the point of Frank's story on nurse practitioners because it features no symbol representing them. Actually, it features two. The fact that NPs can be identified with both the cap and reflector without having a symbol to call all their own is why they've been described as the "invisible provider."

NPs are fast becoming visible. They may be a contributor to premium stability for HMOs, because they can lower group practices' cost of providing care. They're a source of irritation to physicians as NPs gain authority to practice independently.

The AMA sees this as a threat to quality, but are doctors really needed to render all primary care? Would their skills be put to better use tackling difficult cases? This isn't to suggest that NPs are equal to physicians. We think, however, that just as primary care physicians know when to call in a specialist, likewise NPs realize the kinds of cases they can't handle.

In five years, if we decide to revisit the status of NPs, we may very well put a symbol on our cover that is theirs alone.

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.