John A. Marcille

John A. Marcille

We're in a quandary, says Paul R. Berger, MD, a consultant with William M. Mercer, pointing out that consumers do indeed mind having to pay more for choice. Technology has so often been pointed to as coming to the rescue of the health care system that you'd think that by now an expert such as Berger might be looking to another solution. You'd think wrong.

"The next phase of managed care that we're going to see over the next three to five years is going to include the notion of what we call high-performing networks," says Berger. "We're going to try to find, through the use of very credible software, which specialists are efficient in treating or giving diagnosis through what we call an episode of care. Employers are going to want that data, and are going to steer their people to the more efficient specialists."

Senior Editor Frank Diamond asked Berger about specialists during the course of research for our cover story on that topic. That consumers want less-impeded access to specialists is best illustrated by the dramatic rise of PPOs. "The growth in PPOs is fairly dramatic, and it's basically taking business away from the HMO platform," says Berger.

Berger is not the only one placing hope in technology. Alain Enthoven, PhD, has been promoting his managed competition theory for nearly 20 years now. This time he thinks it might take, partly because the employer-based system, in his view, has failed, and partly because new technology makes his proposal even more practical.

Making it work, in fact, is the unspoken subject of all our features and departments. From how coupons can help curb drug spending to Wendy Everett's look at pressures on the health care system to plans' need to use the proceeds of premium increases to better position themselves in the marketplace.

That progress can't solve many problems, and can even create new ones, is somehow beside the point. Like it or not, it's coming and folks like Enthoven and Berger and Wendy Everett, ScD, of the Health Technology Center and New England Healthcare Institute are encouraging you to catch the wave

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.