John A. Marcille

John A. Marcille

The American Medical Association first recommended annual physical examinations of healthy people way back in 1922. Even though the clinical value of prevention was decades away from truly being understood, physicians' sixth sense told them that from the standpoints of morbidity and mortality, it was the right thing to do.

When HMOs burst on the scene half a century later, they, too, embraced the value of prevention — for a different reason: There are many areas where disease prevention is less costly than treatment. Managed care made a bold proclamation that indemnity plans never dared say: "We'll pay to keep you well."

So if everyone's at least in agreement that preventing illness should be a common goal, why is a mutual understanding of "prevention" so elusive? As this month's cover story illustrates, health plans, employers, and physicians chant prevention, but when seeking guidance they don't always turn to the undisputed bible: the work of the U.S. Preventive Services Task Force.

Some blame is borne by employers, who often expect up-front savings. In other words, if a preventive service adds to premium costs, it's no good — and the benefit's not worth buying.

Political pressures contribute. The National Committee for Quality Assurance, which develops HEDIS measures, had a big row about whether to expand its mammography requirement when it was pressured by HCFA to include women over age 69. Ultimately, NCQA stuck by the USPSTF position that the benefit of routinely screening women 70 and older for breast cancer is uncertain — and left the HEDIS measure unchanged.

Then there's personal responsibility. Truth is, despite all the promotion plans do about prevention, few people seek it. Left to their own devices, only half of women would get annual checkups. Child immunization rates would be in the 60-percent area. At some point, you have to wonder whose problem this really is. One thing is certain: If this country is to become healthier, we need to get on the same page about prevention.

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.