Frank Diamond
Managing Editor's Memo

Even in the working-class neighborhood of my youth, the idea of prevention — while occupying nothing like the cult-like status accorded it today — did, in fact, have currency. It was called the yearly checkup, and everybody who wore a hard hat and carried lunch in a rectangular metal container was nagged to get one by others who heard about this or that going around while hanging their wash. (The wash-hangers would in turn also be nagged.)

Records on just who heeded this advice and who didn't are difficult to come by. I do, however, remember the rebuttal: "I don't want to know."

Even back in 1962, that did not translate, exactly, into "Who could possibly know?" However, it seems that it might have been what some people were getting at.

Our cover story on genetic testing suggests that people will soon be able to know a lot — in some cases, an awful lot.

Not to belabor the point made by our cover illustration (oh, OK, you caught me, I am belaboring it): Genetic tests open up a raft of coverage issues.

Contributing Editor Maureen Glabman deftly guides us through some of the issues that not too long ago seemed a lot like science fiction. She also offers case studies of health plans that have decided that genetic tests and prevention go hand in hand.

Of course, it's never that simple. What about very expensive tests for very rare conditions? Or a genetic test that's 90-percent accurate versus a more traditional test that's 80-percent accurate?

Tough decisions lie ahead. Unlike the strong men and women of my youth, we cannot simply throw up our hands and say: "I don't want to know."

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.