Our cover story talks about private-label health plans in which Aetna offers large providers stake in the insurance side of the business. Aetna — and other health plans that might try this — hopes that working with the dominant local provider in an area will increase market share in places where they’re either running behind or out of the running.

I suspect this to be one of the early ripples before a tsunami of unforeseen consequences — both good and bad — of the Affordable Care Act.

A private-label health plan offers an alternative formula for competition to providers who do not want to join an accountable care organization (ACO), whether for operational or financial reasons. It comes down to this: Cost-cutting is not a growth strategy for hospitals, but becoming a plan sponsor might be a way to come to terms with the new methods of payment.

And some of our ideas about where to cut costs may be wrong.

A study in the Journal of the American Medical Association last month notes that trying to avoid emergency department care for the costliest Medicare patients by treating them in physicians’ offices instead won’t save as much as some experts had hoped.

Karen Joynt, MD, MPH, the lead author, tells Reuters Health, “It’s a more complicated problem than we thought.” But isn’t it always.

Answers to such vexing dilemmas might be found anywhere, maybe even across the vast Atlantic Ocean. Which brings us to our new department The Wider View. Our man in London (I always wanted to say that), Robert Royce, PhD, will report on how health care fares in the old world. Or doesn’t fare, as the case may be. Now an independent consultant, Robert has had a strong career in health care in the United Kingdom, most recently as director of strategy at Barking, Havering and Redbridge University NHS Trust in greater London.

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.