Is managed care dying — or evolving? While few think managed care is going away, there's sharp disagreement on the form it will take in the future.

No doubt, MCOs are less restrictive than at one time. Paul Ginsburg, head of the Center for Studying Health System Change, told a Robert Wood Johnson Foundation conference on the future of managed care that health plans have accommodated physicians' and members' concerns — but perhaps at a long-term cost of inability to control utilization.

This has led to talk that plans eventually will decide the frustration isn't worth it and delegate cost-benefit trade-offs to consumers. But HMO executives present said that for all the talk of defined contribution, such a shift is unlikely soon.

Aetna's CEO, John Rowe, M.D., predicted that if the economy continues to soften, employers will migrate back to more tightly controlled plans.

At the same conference, University of California researchers presented evidence that MCOs provide the same quality of care as fee-for-service medicine. Their assessment was based on an analysis of more than 70 quality-of-care studies.

One hundred eighty degrees from these perspectives, a University of California–Berkeley economics professor predicted managed care's end in a Journal of the American Medical Association essay published the same week of the RWJ conference.

James Robinson, Ph.D., predicted that a "culture of consumerism" would replace employers, doctors, and insurers as the primary decision makers in health care. He labeled managed care an "experiment [that was] an economic success but a political failure," observing that managed care's failure to explain how it tries to "navigate tensions between limited resources and unlimited expectations" is its fundamental flaw.

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.