John Marcille

John Marcille

Last month we published a theme issue on wellness and swore: “Never again.” Not because we weren’t happy with the results (we were), but because there’s an inherent danger in such undertakings: If the reader isn’t interested in the theme, he might lay the entire publication aside. Of course, you live and you learn, and February’s issue also included two articles and a host of columns that had nothing to do with wellness. There’s something for everyone.

This month, as we assembled and edited the disparate articles, we found — a theme. It snuck up on us. This theme is about collaboration. You can find it in our cover story about what makes Harvard Pilgrim Health Care so exemplary. HPHC operates in a tough neighborhood where several of the insurers score high in national ranking systems. It’s competitive, but not so much so that those companies won’t cooperate on some things.

“When you think about the fact that health plans are willing to come together in a collaborative and share their data across health plans so that we can get more reliable performance information, that’s really huge. They do that here,” Barbra Rabson, executive director of the Massachusetts Health Quality Partners, told us.

Then there’s our story about how some of the largest HMOs in the country are cooperating in a research network, sharing their own data for the larger good. Cooperatives such as the HMO Research Network will benefit the entire medical system.

The ideas of cooperation and collaboration crop up elsewhere as well, but not in a heavy-handed way. We have health care companies working with employers, for example. But don’t despair! We also have conflict galore. As I said, there’s something for everyone.

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.