John Marcille

John Marcille

It seems that every year we publish at least one “what’s old is new” story. But really, why shouldn’t that be the case? When an old, discarded idea comes around again, maybe it means that it should not have been discarded in the first place.

The return of capitation was one such article; another was on renewed interest in delivering care at home. And this month, it is the return of the closed formulary. Let us be clear: The kernel ideas are old, but there is always some new spin on the implementation and sometimes even the rationale. They are never exactly the same — not the way Twinkies are, to take a frivolous example. At least I assume Twinkies are the same; I haven’t had any for at least 10 years and then it was only to find out if they were as good as when I was a boy. They weren’t, but I like to think that it is I who have changed, not the venerable Twinkie.

Not so with the closed formularies. To tell the truth, we may have stretched the truth a micron or two with our headline, because often these new closed formularies have escape hatches. That’s because we’ve learned a thing or two during the past 20 years. Our story by our former managing editor, Mike Dalzell, is very much about the present and the future. So don’t think of the old-is-new story as a “we’ve come full circle.” Think of it as a spiral, going around in circles in two dimensions, but making progress in the third and fourth.

Briefly, let me mention just two of the 15 feature articles and departments in this issue. Al Lewis, president of the Disease Management Purchasing Consortium, has written a fascinating and controversial book about the claims of some population management companies. We have a substantial excerpt that will amaze you. Amaze or dismay. And in the same issue we have my interview with Paul Terry, CEO of StayWell Health Management, one of the leading population health management companies and not one of Al’s targets.

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.