John A. Marcille

John A. Marcille

Though we've held it off for as long as we could, 2008 will soon be upon us. This thought sparks anxiety, and not only because we haven't yet thought about holiday shopping. We all need to think about 2008 and the effect that the presidential election will have on managed care. As our political story on page 38 points out, insurers might want to join in the national debate concerning the industry's strengths, weaknesses, and future.

It's one thing to contribute to the candidates who back your agenda, but it isn't just about getting those candidates elected. More important, in the long run, is influencing the terms of debate. It seems that there is a groundswell of interest in making sweeping changes to the system. That smoke has risen before, with little fire behind it. But don't assume that it will be the same in 2009, when legislation is most likely to be enacted.

Whatever happens, there will be an important place for managed care. The industry's job during the national debate is to help the public and policymakers understand the processes, principles, and successes of managed care and to counterbalance less principled reformers who emphasize anecdotal reports of managed care's misdeeds.

Our cover story on page 22 is about innovations brought about because of influential experiments in consumer-directed health care. This is an area in which the marketplace is working overtime to cope with the cost problem that is one of the drivers of the reform movement. Unfortunately, this focus on consumers will not bear enough fruit in the next year to have much effect on the policymakers.

Access is the other big issue. America's Health Insurance Plans has a full-coverage initiative that has the virtue of being incremental and therefore acceptable to many stakeholders. Will a complex and incremental plan appeal to voters and legislators?

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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.