John Marcille

John Marcille

Prevention remains the mainstay of managed care, and this issue looks at it from different angles. The story explores how dental care affects overall health. Though the evidence is inconclusive, some major health plans have integrated dental and health benefits in unique ways. Dental health is seen as a factor in managing diabetes, coronary artery disease, pneumonia, and problem pregnancies.

Then there is alcoholism. If the secondary diagnosis of substance abuse is not recorded, the information will not be available in the data collection process. Many physicians are still hesitant to make that diagnosis, let alone force a discussion of it. The doctor may be uncomfortable, and of course, lecturing a patient could drive him away. Still, if anybody's going to make the call, it will have to be the primary care physician.

Which brings us to our cover story. As Contributing Editor MargaretAnn Cross reports, the Council on Graduate Medical Education released a paper predicting a shortage of about 85,000 primary care doctors by 2020.

To prevent that from happening, the United States would have to train 3,725 family physicians and 714 osteopathic physicians annually, with an overall goal of a 39 percent increase in family physicians. Yet the number of primary care residencies offered this year to medical students fell by more than 100. And just 7.8 percent (1,107 persons) of medical students participating in the National Resident Matching Program selected primary care residencies, down from 8.1 percent (1,132) in 2006.

The main worry at health plans around the country is that a PCP shortage will leave members with complex or chronic medical conditions without anyone to coordinate their care. Prevention, again.

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.