John A. Marcille

John A. Marcille

When this magazine began over 13 years ago, it was dedicated to helping primary care physicians maneuver through the new and confusing maze of managed care.

We laid out the choice facing doctors: "Resist the changes brought about by managed care and accept a dwindling, unsatisfying practice, or understand the changes, adapt to them, and survive — even thrive." From the beginning, part of what distinguished Managed Care from other publications was its philosophical approach to the industry, one that sought to help physicians seeking to understand and adapt.

Before we came along, physician magazines' take on managed care was pretty simple: evil incarnate. While this approach made for some dramatic reading, it was of little help to physicians in the real world.

We quickly realized that PCPs weren't our only readers; medical directors and then pharmacy directors studied us. Over time they have become our primary — but by no means exclusive — readership.

Our cover piece by Contributing Editor Martin Sipkoff illustrates that while the industry and the publications covering it have changed dramatically over the years, the relationship upon which so much turns continues to be the one between health plan and doctor.

That dynamic appears to be entering yet another phase. Witness our references to new models of primary care. PCPs may gain more respect as health plans recognize and promote their roles in, among other things, preventive medicine and disease management.

The glue that holds together most business arrangements is money. It happens that, in this case, a cohesive doctor-insurer relationship will also do patients, and therefore society, a world of good.

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.