John Marcille

John Marcille

It's not just about wellness anymore. As our cover story shows, for the last three years, employers have been doing much more to improve worker health than simply offering an on-site weight-reduction program (not that there's anything wrong with that).

As we were going to press, a Hewitt Associates study made ripples in the mainstream media. "Nineteen percent of firms installed performance-based medication offerings, waiving copayments for prescription drugs that are proved to be effective and paying a premium for employees to go to higher-rated treatment providers," CNBC reported.

After all, wellness programs, which one expert told us cost about 1 percent of premium to install, are not without drawbacks. "Some employees may resent the [wellness] programs, viewing them as examples of 'father-knows-best' intrusiveness," said the New York Times.

Meanwhile, health plans might be too reticent in this area. Our article by Managing Editor Frank Diamond asks what insurers are missing out on by taking only a spectator's interest in attempts by employers to improve clinical outcomes. Employers know that insurers can participate. For one thing, they have mounds of data that would enhance such efforts, and they trust plans more than they trust providers.

Suzanne Delbanco, the CEO of the Leapfrog Group, touts its Hospital Rewards Program, which rewards hospitals on how they deliver care in five clinical areas. "Additionally, these scores can be incorporated into health plans' existing performance-based incentive and reward programs," she says. "The program is engineered by Leapfrog, with the input of a vast array of providers and health plans, but designed to be implemented by health plans and employers in specific markets." Again: Health plans and employers.

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.