My mother was a favorite at the nursing home where she spent her last years. She retained cognition almost to the end and was what people of her generation would call a wisenheimer. The nurses doted on her, possibly because her reaction to a needle or what she perceived to be an overly rough transfer would be “You’re no Florence Nightingale.”

Or the nicknames. One young physician extender who paid particular attention to her was dubbed “Bad News Betty.” Alas, Bad News Betty cried when Mom died, and I found myself in the ironic position of comforter, reminding Bad News that at 92, Mom had lived a long and good life that the rest of us should celebrate rather than mourn.

Our cover story is about high utilizers and how some health plans have enlisted a band of Bad News Bettys to work with highly vulnerable populations to improve outcomes and cut costs. It’s not a new idea, keeping people out of the emergency room.

Not all health plans are on board and, in fact, Jeffrey Brenner, MD, who heads the Camden Coalition of Health Care Providers, wishes the industry would take more notice of what he’s up to. Ignoring the worst of the worst is no way to run a system, he argues. Especially when 1% of patients account for 21% of costs.

Contributing Editor Joseph Burns lays out how Brenner’s teams of providers helped turn health care service around in one of the poorest cities in the country. What Brenner does may look expensive, but it’s nowhere near as expensive as paying for avoidable emergency department care and inpatient care over and over and over again.

The only way to reach some of the people before they go to the ED is to knock on doors.

Send Bad News Betty.

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.