John Marcille

Reality might have been delayed for a year, but let’s not kid ourselves. The Affordable Care Act is law even though implementation of some elements has been pushed back. Health insurers, like everybody else in the country, face a somewhat uncertain future.

That doesn’t mean you can’t prepare for the inevitable. In fact, as our cover story by Senior Contributing Editor Timothy Kelley points out, there are nine areas demanding attention: Do more for less, deploy narrow provider networks, master new benefit designs, integrate data, learn to align with providers, consider clinicians’ morale, embrace personalized medicine, create a culture of coverage, and keep learning.

We’re learning, all right. Let’s look at No. 1 — do more for less. Peter Boland, PhD, a member of Managed Care’s Editorial Advisory Board, explains that “the only way plans will make margins is to be a whole lot smarter and efficient about how they deliver care.” See how simple it is?

Or No. 6 — consider clinicians’ morale. Physician/insurer friction has been with managed care from the beginning. But the shortage of primary care providers at a time when demand will increase means that plans will have to create payment models that make the work more satisfying.

“Many medical homes around the country have achieved results just on the backs of making the clinicians work harder,” says Paul Sherman, MD, executive medical director of the Health Plan Division of Group Health Cooperative. “They’re all burning out, and that isn’t a long-term recipe for success.”

Remember also that change will be constant. “Like any other landmark legislation, it will continue to need lots of fixes and tweaks,” says Sherman.

We will do our best to keep track.

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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.