John Marcille

John Marcille

You would not be reading this if not for “disruptive innovation” or “disruptive technology,” terms that serve as this issue’s theme. In the magazine business, a disruption called desktop publishing years ago killed jobs, mostly typographers, pressmen, and proofreaders, while reducing costs and allowing many more editorial voices to be heard. As survivors of that revolution, we can see the value of positive disruption.

As our lead story points out, disruptive innovation “is a new technology that unexpectedly displaces an established technology, but only if it is accompanied by an innovative business model.” The article, by contributing editor Maureen Glabman, looks at five innovations that use lower-cost providers in lower-cost surroundings but preserve or, more likely, improve care.

Our popular Q&A feature is with the noted Harvard professor Clayton Christensen, who coined both terms and who explains how these concepts can be applied to medicine. He makes the somewhat disquieting case that network-model health plans may be tomorrow’s dinosaurs. But on page 26, two of his associates take a positive view of the future of health plans — if insurers read and follow the signs. If they can adapt, payers will have far more power than fragmented physicians, other providers, employers, and patients.

Managed Care, launched in 1992, was purchased by our current owner, MediMedia USA, in 1999. In other words, we’re part of a big company now but in the beginning we were very small. Had it not been for desktop publishing, a disruptive innovation, we would not be around at all. It would be prohibitively expensive to hire all the people who were once needed to put out a publication such as this. We’re much more timely, I like to think we have fewer errors, and we have greater internal coherence because of the smaller staff.

So, yes, we understand the challenges and opportunities that disruptive innovation presents. So should you.

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.