John A. Marcille

John A. Marcille

Sometimes, following the changes in health care is like trying to take in several tennis matches at once. You might wind up knowing who won, but you'd be hard-pressed to say how it happened.

Employers want to shift more of the financial burden to employees — hence the growing interest in consumer-directed health care. But what's this? Seems that there's some shifting going on in the public sector as well.

Medicaid may meet managed care in a big way in Florida, thanks to the recent federal approval of a plan that Gov. Jeb Bush hopes will cut skyrocketing spending on the entitlement program.

On Oct. 19, as we were beginning to put the finishing touches on this issue, Health and Human Services Secretary Michael Leavitt approved a Medicaid waiver application that will shift 210,000 beneficiaries in Broward and Duval counties into managed care beginning in July 2006. That's pending approval by the state Legislature, which plans to hold a special session on the matter next month.

Entrusting these beneficiaries to managed care plans can potentially be good for them, while controlling costs. But it will be some time before we know whether they got the details right, particularly a provision that relates limits on a person's care to his historical usage. If it is intended to curb abuse, fine, but after all, health insurance guards against catastrophic costs. Medicaid may not be "insurance" per se, but it has much the same function and purpose.

What's going on in Florida isn't just an exercise in state budget management. It's also an opportunity for insurers to demonstrate their usefulness — again.

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.