John Marcille

John Marcille

Herbert Hoover, of all people, once said: “The trouble with capitalism is capitalists; they’re too damn greedy.” Of course, capitalism has many flaws and they’ve been examined ad nauseam by people who are all too willing to take our culture to task for sins real or imagined.

Perhaps this serves a purpose. An even better philosopher than Hoover stated long ago that “An unexamined life is not worth living,” and I suppose that Socrates could be speaking for societies as well.

However, as those philosophers who write sit-coms too often put it, sometimes you need to get real. Thanks to capitalism, most of us live the sort of lives that our grandparents could only dream of. Heck, we lead the sort of lives that the kings of a hundred years or so ago could only dream of. Capitalism brings us the gold, and what we do with it is our business. Witness Bill Gates, who is endeavoring no less than to save the entire continent of Africa, among other worthy projects.

My background is journalism and it’s been the reflex of journalists to wince in the face of anything that smacks of jingoism. That perhaps is a reflex from that metaphysical insanity known as World War I; I don’t know. Or it might be from the memories of our grandparents who recall the days when big companies would have us all work for a dollar a day.

Where is this leading? Well, directly to our cover story about how health plans must deal with the growing power of providers. There is a tendency to think of capitalism as a zero-sum game, but that is not always so when interests align. Three health plans have developed ways to work with these new powerful providers and I think you’ll find it compelling reading.

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.