John A. Marcille

John A. Marcille

Thomas Jefferson said, "Were it left to me to decide whether we should have a government without newspapers, or newspapers without a government, I should not hesitate a moment to prefer the latter." Of course, Jefferson was not in power when he wrote this in a letter to Edward Carrington in 1787.

It's been a feature of our democracy that we usually have to wait until a politician is out of office before hearing anything interesting from him. This is not to say that Richard D. Lamm, the former governor of Colorado and the subject of our Q&A feature, didn't say interesting things in the 12 years he ran his state.

However, what he has to say now about our obligation to future generations, in terms of the entitlement mentality that threatens to choke Medicare and Social Security, are not calculated to win popularity contests. Catch this exchange:

MC: In 2010 or 2011, I can see the over-65 cohort responding to any crisis in Social Security not with broad solutions but simply by demanding the same benefits their parents had.

LAMM [who is 66]: Who can blame them? I guess I can blame them. This is the challenge. Every society has a challenge to meet the realities that it's faced with. My parents faced a reality called the Depression, then faced realities called Hitler and Tojo.

Tough decisions, and the question of evading or tackling is also an underlying theme of Senior Editor Frank Diamond's cover story about the educated consumer. The tough decision needed: How are we going to pay for health care?

Better education of consumers has been put forward as either an answer or an evasion. If it's merely an afterthought or an alibi for the cost-shifting that most agree is inevitable, then it's evasive.

If it's truly a solution, then all the potential, as well as problems, associated with the educated-consumer concept must be tackled in a responsible way. Are we up to the challenge?

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.