John A. Marcille

John A. Marcille

Every issue of this magazine is devoted to describing changes in the managed care industry. One of our goals is to find the trends before anyone else (especially the mainstream media) and offer information that may help you deal with these developments. We also like to offer "news you can use," the stuff that helps you get through your work day.

Our cover story disregards that template. Instead of telling you what will change, we're telling you what won't change. We're saying that a wholesale change to a defined-contribution system is nowhere near the horizon.

It's perhaps risky to take this stand when most health care periodicals, consultants, and e-health businesses say the opposite. We may appear somewhat less than savvy in our discounting of vouchers. Yet, it's fun to be contrarian — and to point out that it's in the financial interests of magazines, consultants, and, especially, e-health companies to talk up defined contributions. Moreover, if big business wanted such a change, the new administration in Washington would probably sign on.

Within the health care industry, we see some major barriers to defined contributions, such as the tax-structure and risk-sharing issues. Then, there are the employers who don't want to appear to be reducing benefits in a tight labor market.

This is certainly not to say that we're against change as a policy. It's just that you'd better be sure of the Platonic ideal before you disrupt everyone's coffee break.

Rodney G. Hood, M.D., the president of the National Medical Association and subject of our Q&A this month offers a strong argument for change when he says medicine is as biased as any other U.S. institution. Because physicians are trained to help people — regardless of race or any other factors — health officials are less likely to examine themselves for possible bias. As the facts and statistics Hood cites to bolster his position underscore, even unintentional bias can kill.

His call for change is one that should be heeded.

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.