John Marcille

John Marcille

As we were going to press, legislators were weighing whether to extend the subsidy contained in the American Recovery and Reinvestment Act of 2009 (the stimulus) that allowed thousands of unemployed workers to maintain COBRA coverage.

Some stories in this issue of MANAGED CARE deal with utilization, whether overtly, as does our cover story on page 20, or in a less direct manner, such as in the article about when plans should cover new therapies (page 25), our Q&A with Brent C. James, MD, and, on page 31, the article about just what goes on at the pharmacy counter (page 41).... We’ll stop there.

One way not to manage utilization would be to cut it off entirely. No matter how the COBRA debate plays out (we bet that it will have been extended by the time you read this), clinical executives and administrators have an interest in seeing that the unemployed are not also uninsured. Let’s face it: Insurers don’t want to lose covered lives.

But much more important is the human issue — people need care. Subsidized COBRA keeps beneficiaries on the membership rolls, but how exactly to do it?

Jaan Sidorov, MD, a member of our Editorial Advisory Board, says, “My colleagues in the insurance industry need to pay attention to this because this is another corner of their premium income that has been supported by the feds and that is now threatening to go away. While the industry would probably prefer to ride this gravy train, this speaks to the fickle nature of doing business with the government: It’s stop-and-go laced with brinkmanship.”

COBRA is a societal issue. The federal government, through action and inaction, contributed to the mess that we are in now, and it shouldn’t turn its back on those who are truly and intensely suffering because of its shortsightedness.

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.