John A. Marcille

John A. Marcille

We do not provide a quote-of-the-week box. Maybe we should, though some tactical problems would have to be addressed. For instance would the quote be lifted from one of the hundreds of news outlets that run stories on health care each day? Or would it be something someone said to us here at this magazine?

If the latter, then the best feedback this week comes from Peter Kongstvedt, MD, a consultant with Cap Gemini who is quoted in our coverage of the latest Institute of Medicine report. In responding to whether health care in the past ever worked well enough to be considered a benchmark for present efforts, Kongstvedt says: "When was the golden era of any evolving organism? There's not such a thing. It's continually evolving. The environment changes, science changes, the economy changes, and we continue to evolve along with it."

Kongstvedt puts his finger on the difficulty of managing change. The IOM report in question, for instance, points out that, "For several decades, the health care needs of the American people have been shifting from predominately acute care to chronic care."

In its focus on prevention and disease management, some of managed care's goals dovetail with those of the IOM. The report highlights just how.

More change. Our cover story looks at what the new Republican majority in Congress, aligned with the Bush administration, hopes to accomplish in health care policy. There's much on the table and, as one expert puts it, probably only a year in which to do something. (Then comes election-year gridlock.)

In this instance, the amount of change will depend on just how much of a crisis politicians think the current system is in — and how much of an overhaul the public will accept. Memory never sleeps in the nation's capital and the Clinton health care reform debacle seems as fresh as yesterday.

One way or another, however, change is upon us. As Kongstvedt says, we will not be judged on how we stack up to 1950s-style health care. Rather, history will ask whether we proffered the unique answers to the unique questions presented to us.

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.