John Marcille

John Marcille

Political parties gain and lose power, but one chronic reality remains: Nobody has yet figured out what to do about ever-increasing health care costs. This may be a theoretical conundrum for some, but clinical executives are expected to come up with answers, or at least approaches.

Our cover story focuses on how employers want medical directors to find the highest performing physicians. This is an unenviable task. No matter what you do, you know that physician groups are going to cry “Foul!” over the methodology, while some workers will again complain about restrictive managed care. Haven’t we seen this movie? Voices rise to protest limiting access whenever it is tried, and the state of the economy doesn’t seem to reduce the anger.

This time, however, the outrage can be met by answers. Electronic measuring software, federal incentives, and a hard-wrought system for finding the prized doctors are just some of the tools that medical directors can work with this time.

Farewell to a valued colleague

For many years, Martin Sipkoff, a freelance writer in Gettysburg, Pa., contributed feature articles and columns to MANAGED CARE. Martin wrote primarily on matters of interest to clinical executives (this URL will take you to links to 100 of his pieces:, always on the alert for trends, useful or dangerous, that would affect the reader. He and the English language got along very well; when I edited Martin’s articles, I could always concentrate on the ideas, rather than the mechanics. He started out as a freelance writer, and soon became my friend as well. Martin died last month after a long battle with esophageal cancer. We will miss him here and, dear reader, although you will not be aware of it, you will miss him, too.  

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.