John Marcille

John Marcille

The symbiotic relationship between insurer and provider has often made an unexpected turn or unforeseen detour. One new influence points this way, another that way, and who can blame insurers who pause before proceeding?

Our cover story examines the recent work of the United States Preventive Services Task Force. As contributing editor Michael D. Dalzell points out, the Affordable Care Act seems to have increased this panel’s influence. The rulings the USPSTF has made in the last few years have certainly increased its notoriety.

Mammograms? PSA tests? From such buzzwords spring alarmist headlines. What the USPSTF says is often what health plans have been telling providers for years. Is that test really necessary? But for many of these examples, a nudge still might be as far as it goes. Payers who refuse to pay for what some member or provider considers a life-saving test, despite all the evidence to the contrary, sometimes find themselves the subject of a special report on the nightly news.

So insurers in this instance are happy to step back and let providers take the lead — if you can find enough of them.

As we were going to press, the Medical Group Management Association predicted that the United States faces a shortfall of 100,000 primary care physicians by 2020. Those med students are not getting with the program.

Meanwhile, a study in the journal Surgery says that surgical “never events” in fact happen about 4,000 times a year in hospitals. The obvious examples are noted: towels and sponges left in patients or the wrong body part being operated on.

Health plans will not look the other way when it comes to these problems, nor should they.

Providers: You can’t live with them, but you can’t live without them.

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.