John A. Marcille

John A. Marcille

Sometimes breaking old ground can be just as satisfying as breaking new. Take our cover story. The article looks at how the corporate cultures at Aetna U.S. Healthcare and Kaiser Permanente shaped their reactions to recent financial setbacks and positioned them for the future.

What these two plans are looking at, experts believe, is a health care system moving toward defined contributions. Aetna's new CEO, William H. Donaldson, made his reputation by blazing a path for a pension system linked to defined contributions. Kaiser's chief, David M. Lawrence, sees defined contributions as being part of a myriad of health benefits choices that the consumers of the future will have.

This focus is perhaps the most encouraging thing to arise from financial instability. Despite the heavy hits they've taken, Kaiser and Aetna are still savvy enough to spot a trend and ambitious enough to capitalize on it. Both of them. For, as many experts pointed out, the plans seem to be "moving toward the center."

But are they? More to the point, where is this middle that everyone is so fixated upon? Is it the halfway point of patient and/or physician satisfaction, located somewhere between the largest not-for-profit and for-profit organizations? That suggests that Kaiser and Aetna are the yin and yang of the health world. Are there really no plans more bottom-line oriented than Aetna, or physician-friendly than Kaiser?

The two, we have said, should not be compared because they must answer to different masters. Further, this review probably couldn't have come at a better time for Kaiser, or a worse one for Aetna. Kaiser recently announced a huge profit. Aetna is taking a beating.

Our bottom line does not involve tracking how they may be moving toward each other. It's more important to see how both Aetna and Kaiser are moving into the future.

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.