John A. Marcille

John A. Marcille

In the managed care industry, it’s not uncommon to think of providers as resistant to change, protective of their historic turf, and unappreciative of the real contributions that health plans, PBMs, and DM companies make toward patient care. These perceptions are often correct, though not all the time and not everywhere. After all, it’s not a black-and-white world. Context counts.

Managing Editor Frank Diamond’s cover story on the Geisinger Health System’s ProvenCare program of standing behind its coronary artery bypass graft surgeries certainly needs to be read in context, and Frank makes the context clear. Geisinger is an integrated system, with both insurance and provider arms. These arms have embraced a program in which, to oversimplify, the hospital guarantees a price for the surgery and — the new thing — coverage of post-operative complications for 90 days at a total cost that, as we understand it, is well below historical charges.

It seems to work for both sides, and if it does, there is no reason, in principle, that it cannot work with hospitals and plans that are unrelated. For our clinical readers, the payoff is in outcomes: The only way the hospital can make out under such a deal is to reduce post-operative complications, and it is doing just that, by improving systems of care.

This isn’t exactly classic pay for performance, but the goals are the same: reasonable cost and improved quality. We’ll be seeing more such experiments in the coming years, partly because of Medicare’s decision not to pay for some costly and preventable “never events.”

Also on the P4P front, Tom Kaye, senior pharmacy director at Passport Health Plan in Kentucky, lists reasons for insurers and PBMs to attempt to negotiate performance standards and incentives with retail pharmacies, which right now are not working very closely with other parts of the system (even though they’d be thrilled to see all scripts arrive electronically).

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.