John A. Marcille

John A. Marcille

Disease management is one of those things that are forever on the verge of something. Year after year, we monitor the ups and downs of this dynamic industry. I say dynamic because no other topic creates such passionate interchange between the editors and writers here, and it is the subject of frequent articles.

Don't get me wrong. When we write about pharmacy utilization, or wconsumer-directed health care, or patient satisfaction, we routinely contact those who are quoted, to assure accuracy and fairness. Often, with these and other topics, there's some heated discussion about just what was said (or wasn't), and what was meant (or wasn't).

However, it's nothing like what happens with disease management. In conversing or corresponding with quoted sources and other experts on a DM article, we usually do not find the restrained analytical tone that experts involved in other articles display.

Sometimes, all heck breaks loose. I have pondered this for most of the years DM has been on the scene. Part of the reason, I believe, is that DM — with its vendors and healthy (I think) obsession with the bottom line — is still an area where we're mostly going on faith, although this is finally changing. Part of it has to do with DM's uncertain future. It's less uncertain now, though: As our cover story points out, CMS has jumped into the DM waters with both feet. That counts for something.

Arthur O'Shaughnessy, quoted by presidents Bush (George W.) and Roosevelt (Franklin D.), wrote in his poem "Ode": "For each age is a dream that is dying, or one that is coming to birth." With the government support, we know a bit more about where the industry fits in the circle of life. Maybe that will calm the waters.

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.