John Marcille

John Marcille

There’s a lot about technology in this issue. A story examines how health plans are dealing with the genomics revolution. Read about some amazing patient-monitoring systems that promise a bright future for disease management. Then get a glimpse at how information technology might at last foster greater cooperation between health plans and provider networks.

I say “might” because I am a realist and so is the author of that article, Emad Rizk, MD. He cautions: “I am fond of saying that changes in health care come slowly because too many of us think we must boil the ocean before we can drink the water.”

I have been covering the managed care industry for about 17 years now and every once in a while I’ll edit a piece on just why health plans and doctors are tired of all the fussing and would just like to get along. Then the real world bursts in.

That’s as good a transition as any to our cover story. Contributing Editor Maureen Glabman lays out how health plans have more and more become the targets of litigation by providers, primarily physicians. It seems that doctors have much less compunction about going after a health insurance plan if they can do so as mostly anonymous participants in a class-action lawsuit. In the article, Maureen outlines how insurers can protect themselves.

Human nature hasn’t changed all that much, despite our technological advances. Please understand that I am not placing the blame solely on doctors. There’s plenty to go around in this tale of antagonism and mutual distrust, as Dr. Rizk implies.

Still, the mantra of hope is very much in vogue these days, so let’s grasp at straws. I understand that the Irish ceasefire still holds.

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.