John Marcille

John Marcille

Change comes at all speeds, but for the sake of this discussion, let us consider two: slow and fast. Our cover story concerns incremental change. Contributing Editor MargaretAnn Cross focuses on three national pay-for-performance programs that are innovative and substantial. They are efforts by the Centers for Medicare & Medicaid Services, the Integrated Healthcare Association, and Bridges to Excellence.

They show promise for improving outcomes and cutting cost, but we must temper our enthusiasm, because these are essentially building blocks in the slow construction of a national P4P system, and there remain a lot of questions about whether this will be anything more than a minor adjustment to the system. Indeed, some physicians are dismissive of the whole idea, and some commentators argue that the movement could even have an overall negative effect. If all providers are given a pay incentive, what's the point? If some don't qualify, should we be using them at all? Is mediocrity in medicine acceptable?

Then there's fast change, as seen in Medicare private fee-for-service plans. Turn our backs for just one minute and the next thing you know, the fastest growing Medicare Advantage option in the country is one that seems barely managed at all. Everybody likes PFFS: doctors, who get paid more than in other Medicare programs; health plans, because they get a lot of money from CMS; and beneficiaries, who enjoy access to services, even if they are not thrilled by the balance billing. (As we were going to press, an advocacy group called the Medicare Rights Center issued a report saying that PFFS enrollees are not getting the sort of benefits that they thought they'd get. Backlash alert!)

Still, we doubt the long-term viability of PFFS plans, because what makes them so successful is spending that's oblivious to demography. The incrementalist P4P will be with us long after Medicare PFFS is history.

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.