John A. Marcille

John A. Marcille

With American health care in turmoil (have you known a time in the last, oh, 40 years when it wasn't?), it's easy to point fingers. It takes more effort to suggest thoughtful remedies. But following through — now that's the hard part.

As this issue of Managed Care came together, it was not lost on us that its content is prescriptive, perhaps even activist. Some oxes will be gored, and some of our readers' ways challenged. We don't necessarily agree or disagree with anything between our covers; rather, we are a forum for ideas that stimulate discussion.

At the root of health care's turmoil is that we have no health care system. System implies connection, but there are few industries as disjointed as health care. Our cover story, by two Milliman USA partners, examines how competing constituencies pushing various agendas are contributing to runaway expenditures. The writers' antidote is one part sacrifice and many parts common sense.

Perhaps nowhere in health care is there a bigger disconnect than in behavioral treatment. Our article on women's mental health highlights the risks in separating mental from medical care, and suggests that by neglecting prevention and risk-screening strategies, health plans have left education up to pharmaceutical manufacturers, whose DTC ads keep medical directors awake at night.

Alan M. Muney, MD, chief medical officer for Oxford Health Plans, adds to our theme, arguing not only that evidence-based medicine should be the standard, but that physicians be held accountable — pecuniarily and through license suspension. If that seems harsh, consider the IOM's 1999 report on medical errors, which fingered practice variation and lack of systems.

The IOM report brought consistent attention to the need for practice improvement, which is the basis for a new bimonthly column on how innovative ideas in this realm are being put into practice. Our maiden column is an overview of concepts to be covered in the months to come.

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.