John A. Marcille

John A. Marcille

It's too easy to become jaded when you cover a beat. Too often on our beat — managed care — we are left facing the same problems year after year until it becomes a challenge to notice if anything has changed.

"Will physicians ever buy into disease management?" "Can HMOs really offer more choice while keeping premium increases reasonable?" "Why can't health care become more Web-savvy?"

We are not the only ones to occasionally give into the temptation to throw our hands up and say "Nothing will ever change." (The cop who does that has become a stock character in movies — and he's usually hit with tremendous change on the day he's set to retire.)

In this new year, it is fitting that those in managed care, as well as we who cover the industry, reach for an awareness that change can be directed. Notice I didn't say that change can occur. Change is always occurring. As the philosopher G.K. Chesterton noted: "If you leave a thing alone, you leave it to a torrent of change. If you leave a white post alone, it will soon be a black post.... But this which is true even of inanimate things is in a quite special and terrible sense true of all human things. An almost unnatural vigilance is really required of the citizen because of the horrible rapidity with which human institutions grow old."

Many know this intuitively. Hence the innumerable conferences, workshops, and seminars. Our cover story mentions how private and public health care officials in the U.S. journeyed to London to investigate a new agency that seeks to regulate standards and determine coverage of new medications.

The article by Senior Editor Frank Diamond also asks: Could such an agency be launched in the United States? — a perhaps naïve question in light of political and budgetary realities, but worth asking, however, as we observe and influence the development of the "white post."

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.