John A. Marcille

John A. Marcille

Qualilty — by which we really mean "high quality" — is something that we all pay lip service to. I mean, you arrange for really good care for your beneficiaries, don't you, just as I arrange for useful articles on cutting-edge topics. And so on.

From time to time, however, we have to face reality. Nobody's perfect, and that goes for the health care delivery system. I'm not even going to mention that article in the March 16 issue of the New England Journal of Medicine, the one titled "Who is at Greatest Risk for Receiving Poor-Quality Health Care?" by Stephen M. Asch, MD, MPH, et al, that found that "participants received 54.9 percent of recommended care," and that pretty much went for all sociodemographic groups.

I am going to mention a survey taken by about 550 physicians, health plan leaders, employers, and government officials at recent "State of Our Health" forums sponsored by AstraZeneca, and about 350 purchasers who read Employee Benefit News.

This survey (of the understanding and attitudes) of these leaders reports that "Almost uniformly, respondents stated that they did not believe the health care system is driven by quality." Employers were more emphatic, but even three-fourths of the providers and others attending the forums felt that way.

It's important that we know this, but we must also recognize that many or most of us are truly eager to engage in programs that will improve quality. We have loads of P4P programs being tried out across the land, for example, and we have pretty common agreement that "best practices" offer a solid route toward better care, and better value as well. Also wellness and consumer programs.

Our hearts are in the right place. Now we need to perfect the systems and, oh yes, make the economics work.

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.