John A. Marcille

John A. Marcille

You've got this little nagging pain in your shoulder, but sometimes it's more than just a "little" pain. It's a big pain. In the shoulder. You've had to reach for the aspirin bottle a few times and that's saying something, considering how your eyes have been so irritated lately you can hardly see. More than irritated, in fact. Real scratchy. And speaking of scratching, you've been bothered by what you thought is a mosquito bite on your ankle but now, you don't know, because it's looking more like a lump and there's a rash all around it and that's not just because you've been, well, scratching it.

You ought to make an appointment to see your primary care physician. If you want to gamble on waiting that long, that is. If I were you, I'd call an ambulance right now. Relax. You can read something while you wait. There's a story here, for instance. It's all about the worried well.

Who are they? (Are you sure two aspirin are enough? Two might help that pain in the shoulder, but what if you're having a heart attack? Is it too late to start on baby aspirin?) They're the people who think they're sick, but who are actually as healthy as....

That's right, they utilize a lot of services that they don't, strictly speaking, need. They're a little bit difficult to pin down, though. They have a lot of psychosocial distress, but not so much that they qualify for a psychiatric diagnosis.

David S. Sobel, MD, MPH, the director of patient education and health promotion at Kaiser Permanente Northern California, says that as a "result of their worrying, they're actually sick, meaning they're experiencing symptoms and they're suffering." There are ways to combat this problem, he says, and describes some.

Look, there's no silver bullet to tame health care inflation. We need to chip away where we can, and while the worried well deserve our attention, we do have the opportunity to trim some utilization without hurting them in any way, if we are sensitive about it.

Elsewhere, there's an interview with another physician — Howard Dean, MD, the former governor of Vermont who's running for president. Of the United States. Has ideas about how health care should be run. Looks healthy too. Not bullish on managed care, though.

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.