John Marcille

John Marcille

For years, we sometimes felt as if we spent our days trafficking in a dead language. We threw terms around such as accountable care organizations, pay for performance, meaningful use, and bundled payments. Now, as Managing Editor Frank Diamond’s cover story on page 14 points out, those phrases may soon become common rhetorical currency.

“What this means is that the cost-containment initiatives that most insurers have been conducting for years under the radar have become mainstream,” consultant Michael Millenson told us when we explored the opportunities that the health reform law presents to insurers. And Jeffrey Kang, MD, MPH, Cigna’s chief medical officer, makes much the same point in my conversation with him on page 40. He adds that there will be parallel efforts to improve quality.

Health reform also means a fresh emphasis on primary care, a chance to “create a new network strategy,” in the words of another consultant, Linda Havlin of Mercer.

As we were going to press, a story broke that the Philadelphia region’s largest health plan, Independence Blue Cross, will launch a pay-for-performance model that could, for instance, reward a doctor treating 850 Independence patients an extra $150,000 a year for a job well done.

But get this line from the story in the Philadelphia Inquirer: “A key element of the program rewards doctors who meet standards as so-called patient-centered medical homes. Such practices offer greater access for patients, follow treatment guidelines, educate people to better manage their own health, and prescribe drugs by computer.” You don’t say? Look at MANAGED CARE’S Web site and you’ll find that we’ve been reporting on “so-called” medical homes for years. We can’t wait for how the consumer press covers the launch of the ICD-10 code set. We always knew that if we were patient enough, the rest of the world would eventually catch up.

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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.