John Marcille

John Marcille

Industrious human beings love to tinker to figure out better ways to do things. Probably one of the beauties of living in the United States is that such tinkering is not discouraged because entire financial empires have sprung up from somebody just trying to work it a little differently. We’ve taken tinkering and commoditized it.

Even science, with its strict procedures and close attention to cause and effect, bows to this idea. You never know what can come from blue-sky research, or from just getting out of your office and walking about.

As our cover story relates, one day Ken Kim, MD, a hospitalist and CMO at CareMore, was making the rounds. CareMore serves Medicare patients, and on that particular day Kim was horrified to find that 10 foot amputations were needed. Something needed to be done so the plan created a wound-care program that Kim describes as very unusual. CareMore also describes it as very successful, with the result being a reduction in diabetic amputations of more than 50 percent, according to CareMore CEO Leeba Lessin.

The point for me, at least, is that we can be dazzled by new technology — pharmaceuticals, surgeries, devices, whatever — but process improvement often pays bigger dividends. The story looks at two other health plans and their efforts to improve processes. The problems those plans — HealthPartners Medical Group, and Kaiser Permanente — faced did not present themselves in such a dramatic fashion. Still, the medical directors and others couldn’t leave well enough alone. They thought that there must be a better way to ensure appropriate use of imaging (HealthPartners), and that variation in quality across facilities and regions might be eliminated (Kaiser).

They came up with better ideas. It’s a challenge all of our readers face every day. Hopefully, these success stories will inspire more success.

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.