John Marcille

John Marcille

Managed care is a topic that’s hard to avoid even in one’s casual reading. In “The Doctor’s Office,” a regular column that appears in the Wall Street Journal, Benjamin Brewer, MD, laments the changes in his profession. The complaints will sound familiar to readers of this publication as, for instance, when Brewer states that “Somewhere along the line too many doctors stopped being healers and became prescribers and technicians.”

That’s a frequent complaint, and worth addressing.

“I can’t put my finger on a day the profession was transformed,” Brewer says, “but the change is driven home every time a health insurance company calls me a ‘provider’ instead of a doctor.”

Brewer understands that this is a nod to those health care practitioners who are not MDs but who treat patients, but it still rankles. I do sympathize with Brewer and I think health plan administrators should as well.

However, when Brewer complains about not being able to spend as much time as he’d like with patients and points to managed care as the cause, he leaves something out. There are fewer caring family practitioners like Brewer in the market. About 70 percent of medical school students are graduating as specialists.

The money isn’t as good in primary care, and the hassles seem to get worse each year. It’s quite expensive to run your own business, for instance. Brewer states that “there are months when the practice isn’t profitable.”

The crisis in primary care can present itself as an opportunity to health plans. If insurers do all that they can to ease the burden on PCPs then who benefits? The entire health care industry, that’s who. Including health plans. Perhaps the burgeoning advanced medical home movement will make a difference. Something to think about as we await the changes that a new presidential administration will bring.

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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.