John A. Marcille

John A. Marcille

Those who are quick to disparage management by committee probably would be just as quick to disparage management by despotism, if they weren't so frightened of the despots. American entrepreneurial spirit has seeped into the most formal of businesses to facilitate a free flow of ideas. Or at least that's the aim.

Contributing Editor MargaretAnn Cross's cover story shows how health care is as attracted to the possibility of mining expertise as any other industry. Her article demonstrates how the formulary committee has been opened up to admit more than just those players who are still the recognized mainstays of those bodies — physicians, medical directors, pharmacists. Specialists, nurses, and PBM personnel are now coming aboard. Epidemiologists, statisticians, and actuaries aren't far behind. The chart reveals a whole category called "other."

Thanks to a rash of new agents flooding the market — and set against a backdrop of increasing public attention focused on access and out-of-pocket costs — P&T committees are expected to do more, review more, and take more into consideration when making decisions. As a result, they have been forced to go after experts they may not have needed in the past, and in the near future may have to go even further, tapping geneticists and ethicists to unravel the complications that genetic medicine will introduce.

What comes out of such committees is so vital that HMO physician executives seek extra training on the best ways to run such meetings, a point made by Alan G. Adler, MD, MS, the interim chief medical officer at Horizon Mercy, a Medicaid HMO in New Jersey. His first-person account about being coached in executive skills is all about listening. Ditto for our Q&A feature, in which Bob Stone, a DM lifer, explains how that niche industry has listened to what customers want and is evolving as a result.

Change is vital, even if it doesn't come easily. Yet not all change is desirable. Near the back of this issue, our thoughtful ethicist, Michael Victoroff, MD, discusses the utility of full body scans, and finds some reasons not to embrace the new.

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.