John Marcille

John Marcille

Television news outlets scream for attention every minute of every day. Newspapers sometimes have three or four stories that might deserve the headline above the fold; sometimes nothing makes the grade. Still, they publish even when news is slow. There always has to be a headline or lead story. One day it may be man walks on the moon, or the discovery of a bacterium that’s able to use arsenic in place of an element previously considered essential for life; the next it may be man buys new car.

After a while, consumers might get a bit confused as to just which story means more. I am being facetious to make a point: The adage about journalism being history’s first draft doesn’t help those of us trying to prioritize.

I have no doubt that 2010 will go down as a watershed year for managed care. There’s just no ignoring the fact that the overhaul of the nation’s health care system, which had been a goal since the Truman administration, finally occurred. Damn it or bless it, you can’t ignore the Patient Protection and Affordable Care Act.

Health care reform will have an effect on most of the subjects touched on in this issue: from our cover story on the challenges in managing specialty pharmacy, to our look at how new technology (in the form of mobile and social media) might make change more possible, to how nurses and pharmacists might fit into the system.

Clinical executives face new challenges, and will be asked to come up with solutions. And I am not too proud to ask you, the reader, for answers — using, of all things, new technology. Our story about ER overutilization offers an interactive opportunity that allows you to discuss how you attack this problem.

Like you, we’re modifying our approach. Like you, we have to.

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.