John A. Marcille

John A. Marcille

"Louise" lives in the Logan Circle section of Washington, D.C., in a five-story Victorian brownstone, though she also escapes on weekends to her farm in Virginia. "Harry" lives in Los Angeles. They're not together anymore. Actually they were never together, at least not in real life.

"Harry" and "Louise," as you may recall, were the husband-and-wife characters in ads that ran in 1993 that helped to sink the Clinton health plan. That legislation, spearheaded by then First Lady and now Sen. Hillary Rodham Clinton, was going to reform health care, or sink it, depending on whom you talked to. There was never any doubt about how Harry and Louise felt:

Harry: Government-run health care! Congress can do better than that!

Louise: They will if we send them a message.

Americans sent over 250,000 messages to Congress saying the Clinton plan was not the health care reform they wanted, an unprecedented show of grassroots support.

Now, as we begin the off-year election cycle, you hear . . . very little. Very little about evil HMOs. Not even much discussion about a patient's bill of rights, which was supposed to make HMOs more legally accountable for denial of care decisions.

My guess is that cost is so much the issue now that the overblown complaints about improper withholding of care are yesterday's news. Part of this may also have to do with the rise of consumer-directed health plans, which push much more of the responsibility and cost for care onto patients. Still, as recent statements from Sen. Clinton suggest, the managed care backlash may not be entirely played out. If there's political capital to be gained from bashing HMOs, then who can say for sure that we've seen the last of Harry and Louise?

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.