John Marcille

John Marcille

The promise of managed care has always had a lot to do with what its advocates hoped would be the ability to provide care for populations, not just individuals. This was a radical concept to many people, and still one that is not too easy to explain to people outside the industry.

Early commercial HMOs especially were not too adept at delivering, and no wonder. Just getting their systems to hang together in the face of skeptical providers and the public was a big order. But as time goes on, and information technology advances, plans' ability to deliver on this promise gets better and better.

One example is the cover story, which emphasizes a new commitment to prevention on the part of many insurers. Prevention is an activity that produces long-term economic gains, which can be a problem for businesses struggling with this year's bottom line. Yet in cancer care, prevention as a strategy is taking hold, and as with other prevention activities, all will eventually benefit. Plus, in the short term, to be able to show that you have leading-edge cancer prevention and management programs has to be attractive to employers (who also have to think long-term) and to members.

One place I wouldn't have expected to see managed care involved in is intimate partner violence, but in an article by Therese Zink, MD, et al, we find that by using the Planned Care Model, plans can collaborate with other institutions (e.g., domestic violence agencies) to reduce the incidence of IPV, which may afflict one third of women over their lifetimes and is more common than many actual diseases that health plans screen for and treat.

To care for populations is to care for individuals, and they benefit, even when, as is surely the case, they are not even aware that it is happening.

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.