John Marcille

John Marcille

The dominant health care news for months has been the reform legislation in Washington, and we cannot ignore it. But while we’ve done our share of reporting on this process, we know that there is plenty going on in the managed care industry itself that also deserves attention.

Take our cover story on cybervisits — consultations between physicians and patients over a secure Internet connection. There is growing interest in this, and for good reason. It is economical for plan and patient, allows physicians some flexibility in their work hours (and in some cases, extra income), and generally uses resources in a rational manner. We think cybervisits will catch on because there is little downside and many advantages.

Cost control is the theme of some other articles, too. One focuses on taming the incredible bills for neonatal intensive care (page 28); another discusses replacing the scattershot and overly costly service-by-service system with bundled payments — not a new concept, but one that is getting much more attention (page 42).

We also like the article (page 46) that lays out some of the disadvantages of the high-deductible plan design. We’ve heard a lot from the promoters of this design, and it does have its attractions, but we need to pay more attention to the perverse incentive that it puts on patients to avoid needed care.

Then, too, there’s our regular Plan Watch column. If you work at a health plan, as many of our readers do, you might want to read about how BlueCross BlueShield of South Carolina is helping a group of hospitals improve the capabilities the members of their boards of directors — a positive and productive effort.

And there are other great articles and columns that I don’t have room even to mention. 

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.