John Marcille

John Marcille

I’m really excited about this issue. Major change is afoot in the managed care industry, and we are writing history’s first draft. Take our cover story. For many years we’ve been reporting on pay-for-performance programs, and I always felt that, as well-intentioned as proponents of these efforts were, something was amiss. Does it really matter if a doctor performs well on process measurement if there’s no improvement in morbidity and mortality? Yes, process is vital, but only if the fruit of such process leads to good results. In the real world, outcomes, not the number of pap smears or glucose tests, are the bottom line.

Then look at the article about how the National Comprehensive Cancer Network, an alliance of 21 top cancer centers, has become the agency that Medicare and health plans are turning to in making coverage decisions about expensive oncology medications.

Our Q&A with David Nace, MD, is another example of real change a-coming, this time thanks to the Affordable Care Act (unless, of course, that law is struck down by the courts or a legislative fusillade). Nace, the vice chairman of the Patient-Centered Primary Care Collaborative, says that medical home offers a blueprint on how to make the new focus on providers work.

Of course, often what’s old is new, and vice versa. How many times have we published articles about the importance of adhering to accepted best-practice guidelines? Our report on the opportunity for better management of heart failure makes the case again, and more convincingly, by showing how little expenditure is needed for a good return on investment.

Please, let me know if my hopeful view is warranted.

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.