John Marcille

John Marcille

When we plan an issue, we try to assign a variety of topics that will appeal to most of our readers. Since nearly all of these readers work in managed care organizations, be they health plans or integrated systems or the large practices that do business with hospitals and insurers, it isn’t particularly hard to do.

This month’s cover story should have something to say to nearly every reader. It’s a bird’s eye view of two approaches to health care management that seem, from their names, to be very much at odds with each other. What we found out is that yes, there can be problems, but more and more the care-for-populations approach and the patient-centered approach are not enemies, and in fact, the latter depends on the achievements of the former.

For everyone in health care, the cost of drugs is a problem. Everyone except pharmaceutical companies, that is. I had been interested in the burgeoning practice of pharma companies giving health plan members coupons to lower their out-of-pocket costs so as to keep them from going generic or seeking a prescription for a tier 2 drug instead of, perhaps, a tier 3 drug with a high copayment. This practice raises costs for employers, health plans, and patients in general. So I asked my friend Linda Cahn, a lawyer/consultant who has written some wonderful, highly specific articles on contracting with PBMs (all available free on our Web site,, to advise our readers on how to tackle the coupon problem, and as usual, she came through.

Still seeking variety so that there will be something, if not many things, to interest each reader, I came up with a piece about four trends in managing specialty pharmacy that the author, Ira Studin, tells us will assume major roles in dealing with these costly drugs. And there are a dozen or so other stories, long and short, on the clinical and business sides of managed care.

As always, I am eager to read your suggestions for articles, sent to

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.