John Marcille

John Marcille

If you travel to the south of France, you may find yourself drawn to the lovely scenery in the neighborhood of the Lot River. You may stroll through the streets of a quiet village and let the clean country air fill your lungs.

I just hope you don’t get sick and spend most of your vacation in bed, as happened to me. After nearly a week of self-medicating with Imodium, I sought out a physician. I was in luck. The village had only a few hundred residents, but there was a doctor. I went to see her (two hours after I called for an appointment), she examined me and prescribed medication, and I was able leave my room at Le Galerie, a charming B&B, without fear within 24 hours. Just like that. No forms to fill out, no waiting. And the visit cost me just 23 Euros (about $30).

The medication, it turns out, is unavailable in the United States.

Every month we present articles to help clinical and C-suite executives do their jobs better, but we also pull back and look at the bigger picture, about remedies for the system. Our cover story concerning the obstacles to value-based insurance design is one such macro-look.

Throughout this issue you’ll see various approaches and recommendations for improvement, from our Q&A with Helen Darling, president and CEO of the National Business Group on Health in which she lets us know what big employers want, to our new department called Evidence Review, which is a collaboration with the ECRI Institute that looks at the latest health care technologies. Yet, as our Viewpoint points out, it doesn’t matter unless the consumer sees a clear path.

This is not to say that we should adopt a single-payer system, such as they have in France. It’s merely to point out that when I was down and out in a foreign country, it was nice not having to fill out any damn papers, to have quick access to a physician, and to have a wonder medication that did the job. With our system in such a mess, we could learn a thing or two from others that have high public confidence.

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.