John Marcille

John Marcille

Frank Diamond, our managing editor, in this month's cover story on the resurgence of talk about a standard health insurance benefit, notes the cyclical nature of some political and social issues. A standard benefit may be one of those issues; it certainly was a centerpiece of the coverage design that the Clinton administration produced over a decade ago, and it returns now because it is attractive to many people for social, political, and business reasons.

Unattractive to others, also for social, political, and business reasons. At first I thought that it would be mainly centrists and leftists who would embrace it, but then I remembered our interview with Newt Gingrich last year, and how he wanted to require every American to obtain health insurance. If you're going that route, you certainly need a minimum standard, because if you don't have one, you might as well not have the mandate. Imagine, if you will, businesses that have no health benefit now being required to provide insurance with no defined standard.

Of course, to have a minimum benefit doesn't necessarily mean mandatory insurance; one could craft a plan combining our knowledge of medical care delivery and private business concerns to have a floor policy that would be intelligible to workers buying on the open market and would provide a useful level of catastrophic coverage and some preventive care — both valuable to beneficiaries, employers, and society.

As you browse through this issue, you can hardly fail to notice that three of our five feature stories this month involve data processing — oops! I mean information technology. It seems that electronic medical records, predictive modeling, distance medicine, advising patients by e-mail, not to mention the all-significant, if mundane, world in which claims are processed, are very much on everyone's mind.

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.