John A. Marcille

Big issues in managed care? Depends on where you are standing, does it not? If you are a physician or a hospital administrator, the issues are how many patients you have and how much you are paid for treating them. If you work at a health plan, it’s much the same — along with the problem of how much you have to pass on to the providers doing the actual work.

Or are you a public policy person — a senator or an advocate for a specific sector? Then you might be more interested in legislative and judicial issues. Employers, patients, and vendors all see things differently. Remember the blind men and the elephant.

It doesn’t get sustained publicity, but for employers and for a substantial number of patients and their families, substance abuse is a big issue. Families are sundered; lives are destroyed (metaphorically, and sometimes literally); expenses are burdensome. Our cover story by Contributing Editor Martin Sipkoff looks at how employers and health plans more or less turned their back on this problem, but are now showing signs of renewed interest, including procedures for identifying abusers and treating them. He describes how complex this can get, what with the intersection of mental health and substance abuse, and what several vanguard plans are doing to increase their level of service.

For the patients involved and for the governments that pay, how managed care fits with Medicare and Medicaid is a hot topic right now. The Medicare Modernization Act of 2004 is promoting establishment and expansion of managed care plans this year. Getting a plan started in a short time, however, is no mean feat. Meanwhile, plans are finding opportunities in the states’ Medicaid funding crisis.

The medical director trying to keep a lid on costs is directed to a study by a diverse group of researchers who delve into the cost of coronary restenosis in a managed care population.

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.