John Marcille

Rumor has it that there’s a presidential election going on. You wouldn’t know that, would you, if not for the constant, shrill, obsessive calls for change by both major parties 24 hours a day. Part of me doesn’t understand the fuss. Change is indeed coming, if for no other reason than that we live in a malleable world powered by evolution’s twin pistons of decay and rebirth. Don’t want change? You’re in the wrong universe, bub.

Our cover story by Contributing Editor John Carroll looks at what to expect under a President Obama or a President McCain in the next four years. Surprise! Expect more regulation. Expect more oversight. Expect (dang it!) change.

John’s story notes that those demanding health care reform predict that this election “offers an unprecedented opportunity to move from the generic change they all call for to a specific, nonpartisan agenda that can gain swift legislative approval.” The idea is that there ought to be plenty of areas where most of the stakeholders can agree to improve things, even if, as so often happens, no consensus is reached on a transcendent restructuring of the whole system.

As I write this at the end of September, I’m astonished and depressed by the failure of Congress to act decisively to deal with the economic crisis. We may have had more crisis than we can digest, and it would not surprise me if no major health care reform were enacted. As I’ve noted before, any effective reform would also hurt a lot of companies, and Washington is nothing if not hospitable to lobbyists, who long ago replaced journalists as the fourth estate.

And if no meaningful reform is enacted? A study by the Deloitte Center for Health Solutions says that the number of U.S. citizens who will travel abroad to get health care on the cheap, while relatively low now, is likely to increase eightfold by 2010 — just in time for the next congressional elections.

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.