John Marcille

John Marcille

Putting out a business magazine is a creative venture and, as in all such efforts, much happens that isn't planned. I am often surprised by how articles that are assigned to different writers at different times wend their lonely routes toward the same destination — one that wasn't on the horizon during the planning stage. Lately, all roads (or article research, anyway) seem to lead to consumer-directed health care.

A frequent theme in this, our September issue, is patient adherence, which I suppose can be seen as a suburb of CDHC. Adherence points to that mythic hero, the educated and involved consumer, who is the cornerstone of a system that proponents promise is of the consumer, for the consumer, and ultimately by the consumer. (That's if you don't see CDHC as just some old-fashioned cost shifting in sparkling, trendy clothes. I suspect that when it all plays out there will be substantial evidence for both views.)

We have a story about how pharmaceutical companies are working more closely with health plans and employers to encourage patient adherence with medication regimens. Lobbyist, consultant, and former bureaucrat Jeanne Scott, the subject of our provocative Q&A, wants to see health care come into the information age, with information that patients can actually understand. The Employer Update column talks about how plans are offering "health coaching." Even our cover story on the future of managed Medicare, though not ostensibly about adherence, talks about elements of care (disease management, most obviously) in which adherence plays a vital role. And Mark McClellan is promoting CDHC initiatives in the Medicare program.

Meanwhile, adherence to our role — informing readers — means being constantly surprised and challenged by covering a dynamic industry.

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.