John A. Marcille

John A. Marcille

Silos. We usually use that metaphor when talking about the need to accept increases in one category of spending as a condition of reductions in other categories, and it's most often to justify spending on pharmaceuticals. But silos are where you find them, and coordination of care, the subject of our cover story, is a another example. It's no secret that managing each of a patient's conditions individually can be a bad idea and can be detrimental, but coordination is not all that easy. It has been called the major challenge for managed care in the coming decade, and as luck would have it, there are good reasons for thinking we can make progress down this road.

Peter Kongstvedt, MD, a partner in Capgemini, notes that the interventions are getting better and the databases upon which those interventions rely are becoming more comprehensive. Victor Villagra, MD, president of Health & Technology Vector, a consulting company specializing in disease management, advocates creation of meta-guidelines for multiple chronic conditions.

William R. Gold, MD, the chief medical officer at Blue Cross and Blue Shield of Minnesota, interviewed at length, seems to want the health plans themselves to take a more active role in DM, one of the foundations of care coordination. "Plans have a population and case managers, but few plans have diabetic case managers who only deal with patients diagnosed with diabetes."

Even our Legislation and Regulation column describes one candidate's plan to require private health plans in federal programs, Medicare, and Medicaid to adopt chronic disease management programs. All of this is interesting, and not just in a theoretical way.

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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.