John Marcille

John Marcille

Putting out a trade publication doesn't mean losing sight of just how energizing "hard news" can be. True, our brethren in the mainstream media get to hang their passion on a different headline each day, from the serious (an Iranian strongman's visit) to the silly (Lindsay's in rehab again!).

But name a field that's more in flux than managed care? This month, we look at the proceduralist, and how he might help keep hospital costs down, not to mention improve patient care. We investigate ambitious experiments in cost control, such as the effort to tier specialists, or how one insurer and provider have formed a respectful working relationship to treat cancer. Our Q&A on page 40 features William Winkenwerder Jr., MD, MBA, who wants to bring some lessons to the commercial sector from his old job, assistant secretary of defense for health affairs. He is a longtime member of our Editorial Advisory Board.

Take a look at our cover story. Contributing Editor Martin Sipkoff looks at the legacy of Asheville and how that pharmacy experiment 10 years ago legitimized medication therapy management and made it possible for pharmacists to take on an important new function.

Also, on a personal note, we say farewell to Patrick Mullen, who's been Senior Contributing Editor for well over a decade. Pat, the first managing editor of Managed Care, and later editor, has been an adviser in recent years and has contributed most of the Q&A features. He is moving on to a new opportunity and we thank him for all that he's contributed and wish him the best.

At the same time, we are pleased to announced that our new senior contributing editor is MargaretAnn Cross, who has written many wonderful articles for us for many years. Good luck to MargaretAnn as well.

Whoever said that the more things change, the more they stay the same must have been pulling somebody's leg.

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.