John A. Marcille

John A. Marcille

Journalists pay an awful lot of attention to how articles begin. The lead had better be a grabber, or most readers will wander off to the next story. (Is everyone still with me?)

This month's edition of Managed Care comes with the usual grabber leads. However, a couple of our stories also include endings that shoved me right into the future. For instance, our cover story about the single-payer system is something you may want to stay with until the end. I don't want to give too much away. Suffice it to say that author John Carroll reminded me of how gratifying it is to live in our society.

Since before the founding of our imperfect nation, people have been able to publicly voice their ideas, where those concepts are then tested, tempered, and refined. From this cacophony, change emerges. Sometimes, it is astonishing in its scope.

Look at our story on how health plans are beginning to launch programs that cater to the victims of domestic abuse for another compelling lead, and thought-provoking ending. Since the ending does much more and much less than sum up the story, it can be repeated here. Author MargaretAnn Cross quotes Brigid McCaw, MD, the clinical lead for Family Violence Prevention Services at Kaiser Permanente Northern California.

"Health plans and physicians can say, 'This isn't just a law enforcement problem, this is a health care problem. It's not my job to try to get the person out of this relationship; it's my job to identify and refer.' And that's what we do for all kinds of other health problems; this is no different."

The future questions us.

Who? What? When? Where? How? Why? You don't have to be a journalist to be excited about where the answers might lead.

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.