John A. Marcille

John A. Marcille

Here at Managed Care, we offer in-depth discussions on the complex issues of the day by respected experts inside and outside the industry. Sometimes, however, we address issues informally. When an interesting story breaks, for example, it sometimes makes sense to discuss it in this space, rather than wait a month for a full-blown article that, by the time you read it, might be turning stale.

Which brings me to the announcement that Medicare payments to health plans participating in what was called Medicare+Choice but is now known as MedicareAdvantage will increase by a record 10.6 percent.

This wasn't exactly out of the blue. We'd been reporting for months that one effect of Medicare reform would be an influx of funds for managed Medicare. With this new money, the Bush administration hopes to have 35 percent of beneficiaries enrolled in MedicareAdvantage by 2007. At its peak in 1999, M+C had 16 percent.

We'll be hearing more about this in the coming months. But right now, it seems to us that the question of whether MedicareAdvantage can work is still very much open.

For one thing, the fee-schedule Medicare market is far different from the commercial indemnity market that managed care blew away a decade ago. Medicare is lean and mean already: Ask the physicians how they feel about their fees, and note that it is beyond dispute that Medicare's per-beneficiary overhead is minuscule compared with any HMO.

There will also be the resistance of beneficiaries to being told they may not have certain tests and treatments because they are not indicated. Any extra benefits, however, will not be rejected.

I hope the new program does work out. I believe that true management of care (as well as cost) is in patients' interest, and I hope that the industry will take this gift and do the right thing.

With the proper oversight, managed Medicare will turn out to be one of the most successful efforts in privatization ever.

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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.