John Marcille

John Marcille

Uncle Sam’s approach to health care coverage profoundly affects what goes on in managed care. Sometimes the influence is direct. Check out our stories on Medicare Advantage and MedPAC. Sometimes, less so. See our cover story and the patient satisfaction article.

As we were assembling this issue, the Department of Health and Human Services announced that it wants the switch from ICD-9 diagnostic codes to ICD-10 by Oct. 1, 2011. Never has three years seemed like so short a time.

“I’ve watched the ICD-10 storm cloud approach slowly and learned it will require some extensive retooling in claims processing, actuarial services, and finance,” says Jaan Sidorov, MD, a consultant and former medical director who sits on MANAGED CARE’s editorial board. “From a medical director’s point of view, there are implications for network management, disease and/or care management, and HEDIS.”

The fact that the announcement comes as no surprise does not detract from the coming challenge. HHS lays out both the nature of the test and why it couldn’t be avoided. “Developed almost 30 years ago, ICD-9 is now widely viewed as outdated because of its limited ability to accommodate new procedures and diagnoses,” the agency states. “ICD-9 contains only 17,000 codes and is expected to start running out of available codes next year. By contrast, the ICD-10 code sets contain more than 155,000 codes and accommodate a host of new diagnoses and procedures.”

Many readers by now have boned up on what to expect — at least as much as they’re able to. This is still a breaking news story and all the implications have yet to be explored. We here at MANAGED CARE will be doing just that in the months and years ahead. Change is coming.

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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.