John A. Marcille

John A. Marcille

The things that cost us the most often come without price tags, just as the things we value the most usually can't be bought. Senior Editor Frank Diamond's cover story concerns hidden costs resulting from the oft-strained relationships between HMOs and physicians.

A substantial portion of this figure — whatever it is — is hidden from us. That's because you just can't calculate the cumulative price of countless moments of mistrust.

If magazines had a cutting-room floor, as movie studios are supposed to have, then it would be filled with metaphors, similies, and wonderfully crafted sentences that just didn't advance the story. Here are some lines, cut from the article that we've decided to resurrect here:

Michael L. Millenson, of William M. Mercer, uses a military analogy to describe much of what HMOs want practices to do. He says the U.S. built an entire arsenal of nuclear artillery shells during the Cold War.

"The shells last a certain amount of time, and then you've got to get rid of them," he notes. "We never fired a nuclear artillery shell in defense of Europe. You could argue that having nuclear artillery shells was a useless expense. The counterargument is that the shells deterred war, which would have cost us a great deal more. Similarly, managed care companies will tell you that their administrative requirements prevent expensive waste or episodes of acute illness if best practices are followed. Critics say that interferes with doctors doing their jobs."

Someone once said that it is much more vital to know the philosophy of another country than to know the location and size of its army. Great Britain has a much more formidable fighting force than Iran, Iraq, or North Korea. However, we do not have to be on guard against London.

Thoughts are things; attitude matters. Until hearts change — and the world is full of trouble spots that make the bumps in managed care seem trivial — then costs will mount.

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.