John A. Marcille

John A. Marcille

This magazine, Managed Care, is based in Trenton, N.J., outside of Philadelphia. This affords staff the opportunity to patronize Philly's major league sporting events, an historically dubious perk at best. To be a Philadelphia sports fan is to learn every connotation of long in the term long-suffering.

Then, this year, came the 76ers: that broken, spunky band of basketball scrappers who no one thought could make it to the finals. They did, and while they were defeated by a vastly more talented and healthy Los Angeles Lakers, the team fought hard to the end.

One of the things those of us late to the bandwagon found out, as we perused the sports pages every day during the Sixers' improbable ride, was that basketball players make an awful lot of money. Not just the Allen Iversons and Kobe Bryants. Second- and third-stringers sometimes pull down seven figures.

Isn't it nice to be in demand? Our cover story this month focuses on the provider shortage that managed care, in part, helped to create. For specialists and physician extenders, the want ads on our cover might seem somewhat quaint. Headhunters are knocking at the door long before they have to pick up a newspaper. Will primary care physicians soon bask in the same glow? What will HMOs, already beginning to feel the strain of the shortage, do then?

Perhaps the most intriguing twist in this story is that no one in the late 1990s predicted this would happen. In fact, the prognosticators got it totally wrong, saying that there would be a provider glut.

In business, as in sports ("Go Sixers!"), the unexpected often occurs. That's what keeps us tuned in. The entertainment industry knows this, hence the rush of reality-based shows that try to synthesize this element.

In health care, it will be interesting to see who emerges as the ultimate survivor in what has become a seller's market for providers.

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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.