John A. Marcille

John A. Marcille

We can understand the frustration of Thomas Scully, the administrator of the Centers for Medicare and Medicaid Services and the subject of our Q&A feature this month.

In an article in this issue, Scully says that what has shocked him in returning to government service after 10 years away (he worked in the first Bush administration) is the familiarity of the debates.

"...Since I was last in the government, 10 years ago, nothing's changed," he says. Scully is referring to Medicare and Medicaid, pointing out that there's still no drug benefit for the former, and that states are still locked into old methods of distributing care for the latter. "We just haven't been addressing any of the big structural issues."

We'd like to point out that in the private sector, there has been change. We cite the rise of PPOs, the influence of disease management, and the growing belief by many that defined contribution's time has come. But even the marketplace has limits. Too much change is liable to create a backlash, brought to life by such films as John Q, which is discussed here.

Still, so long as the goals are healing and savings (but in what order?), there will always be enterprising people with enterprising ideas. Our cover story by Contributing Editor John Carroll looks at hospital tiers. If you were to give it a flippant one-sentence synopsis, it might be "John Q meets sober discussion on patient responsibility focusing on the hard truth that choice costs more." Now there's one film that will never be made.

Perhaps the most salient point Scully makes is that true change may take 20 years. Given the recent reports that the government deficit (Weren't we just talking about surpluses?) is expected to reach $100 billion this fiscal year, he probably has a point.

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.