John Marcille

Medical and pharmacy directors at health insurance plans have to always be on the lookout for what employers want. That’s been the nature of the managed care industry and of our entire health care system for decades and still is, for the most part. That qualifier is important. You may have noticed that change is afoot. That’s partly because of health reform. Anything that (dare we say it?) revolutionary is bound to have the “guinea pig swallowed by the python effect.” It will cause a bump for years to come.

This first issue of the new year — our 20th year — suggests how much has already changed. The stories do not focus solely on the employer-health plan dynamic. There’s more going on here, a deeper bow to the idea that doctors, hospitals and patients are business partners as well.

Our cover story about UnitedHealthcare’s attempt to get a grip on expenditures for cancer medications points out that the pilot projects wouldn’t have gotten off the ground without the cooperation of oncologists. Allan M. Korn, MD, the Blues’ chief medical officer, reminds us in an extended interview that about 250,000 people die in hospitals each year for causes unrelated to why they were admitted. He wants health plans to address this problem. Next is a story about how whether the increasing number of beneficiaries who manage their chronic diseases on their own can reduce costs along with symptoms.

Speaking of symptoms (real or imagined), insurers are being asked to guide providers dealing with patients with fibromyalgia. Meanwhile, another story deals with how ophthalmologists and optometrists don’t want stand-alone vision plans to participate in the new insurance exchanges. The story on health information exchanges is particularly timely given that these systems are crucial to the success of accountable care organizations, a provider-centric building block of reform.

There is much to digest here. Enjoy!

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.