John Marcille

John Marcille

We heard a lot about primary care in the early days of managed care. Gatekeepers were supposed to steer patients to specialists only when necessary, and even limit unnecessary treatment. They still do that, but to a much lesser extent. Remember, we also heard a lot about the Patients’ Bill of Rights. The public revolted against what it perceived as tightly managed care. Just how much gatekeeping actually goes on in health insurance these days would be an interesting research topic, I should think.

We often run articles about primary care, since there is evidence that strong primary care is good for patients and good for payers as well. This issue has a strong focus on primary care — even the factory doc or nurse practitioner, as the case may be.

Our cover story explains how some large employers have decided to get into the primary care business by reaching back to the early days of the Industrial Revolution and setting up onsite clinics. Contributing Editor Maureen Glabman examines the dangers for insurers, but points out opportunities as well.

“The largest employers recognize that cost shifting has run its course, and that is part of the reason for the growth of clinics,” Blaine Bos, a partner at Mercer, the consulting company, told Maureen. Where employers lead, some plans will follow. They may get into the clinic business, and that means primary care.

The medical home is intended to be primary care on steroids, and our story investigates the instruments used to evaluate its effectiveness. Then there are the online physician-only communities, such as Sermo, QuantiaMD, Epocrates, and Medscape, which have opened up a virtual nationwide doctors lounge where physicians (specialists welcome!) can trade advice and sympathy.

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.