Patricia R. Salber, MD, MBA
President and CEO of PRS Healthcare Consulting, Larkspur, Calif.
William Bestermann, MD
Medical director, Vascular Medicine Center, Holston Medical Group, Kingsport, Tenn.
Stanley Schwartz MD
Associate professor of medicine, University of Pennsylvania Health System, Philadelphia, Pa.
Albert Marchetti, MD
President and founder, Med-ERA, New York, N.Y.
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Although the prevalence of diabetes has steadily increased in this country for years, recent acceleration of this trend has prompted widespread concern. Poor eating habits and inactive lifestyles contribute to the problem. Because individuals are developing diabetes earlier in life, they will have the disease longer and will require prolonged medical management for an increasingly complex constellation of symptoms. Along with the changing epidemiology of diabetes, there has been a shift in focus from microvascular to macrovascular complications. The impact of these changes, from the perspectives of health, functionality, and economics, makes diabetes a public health concern of staggering import. Standard approaches to the problem do not seem to be working. The diabetes epidemic continues, treatment effectiveness is limited, and costs seem to spiral. The following examination of pathophysiology, treatment considerations, and the managed care perspective will hopefully illuminate issues and initiate a discussion to challenge existing norms and reshape our approach to diabetes care.

Two primary defects contribute to the development of type 2 diabetes: insulin resistance and β-cell dysfunction. Elucidation of the interrelationship of these issues with the metabolic syndrome has led to improved understanding of the underlying pathophysiology, resulting in novel treatment approaches. As clinicians increasingly recognize that diabetes is not necessarily “all about the sugar,” the need for a different perspective on lifestyle management and pharmacotherapy emerges. New agents featuring distinct mechanisms and targeting a variety of defects have been introduced, which calls for an approach to drug selection that matches the strengths and limitations of particular drugs with specific patient characteristics. Managed care organizations may also need to rethink their approach to diabetes. Rather than focusing on drug costs, a broader view incorporating knowledge of the natural history of diabetes may be in order. Acknowledgement that aggressive, early management can alter the course of disease progression and prevent or minimize the impact of costly, debilitating complications can inform novel strategies. These could include value-based insurance design (Fendrick 2006) and a focus on wellness rather than disease.

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.