John Marcille

John Marcille

It is the nature of trade publications to seize on The Next Big Thing. You don't want to read old news, and we don't get any pleasure in producing it, so we and others like us need to present the new and fresh. Headlines are written to grab your attention; that's their function. But let's face it: Most new ideas are combinations of old ideas. Refinements. Expansions.

It's usually evolution, not revolution, that makes the difference. And so we come to our cover story this month — pharmacy and therapeutics committees are increasingly seeking out and obtaining more information, and more appropriate information, about the drugs that they will recommend or reject for formulary placement. Not a fantastic new program or product, but in the long run, very important, very much a managed care function.

MargaretAnn Cross does a great job of examining the work that's being done to prepare P&T committees. This could have been a boring, routine article, but MargaretAnn would never write such a thing. I learned a lot from this article, and I'm as jaded and critical as they come.

This issue was a special pleasure to put together. Managing Editor Frank Diamond reports on an important recent study that offers more evidence that contracting with well-managed large medical groups is the way to go to assure uniformly high quality clinical care. Karen Ferrick-Roman's article on how payers and hospitals in the Pittsburgh area are saving money and giving better service by linking up electronically to verify coverage and manage the patient's progress through the system is surely a case study that looks ahead to how payer-provider links will eventually work throughout the land.

I knew we couldn't go wrong interviewing Arthur Caplan for our Question & Answer feature — and we didn't. Finally, Maureen Glabman takes a provocative look at the pressures on medical and pharmacy managers. Enjoy!

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.