Frank Diamond

Spoiler alert, but only blue (guarded) because the movie Captain Phillips is based on something that really happened. One of the more affecting scenes comes at the end when a Navy medic examines the hero. The director uses a real medic, and Corpsman Danielle Albert plays herself beautifully.

She examines the traumatized hero while asking questions in a manner that mixes clinical detachment with just the slightest pinch of empathy. She’s doing her job. They told her to treat the scene as a drill and anyone familiar with life on a Navy destroyer knows that drills take up a good part of each day.

You don’t have to be in the Navy to identify with that character. Medical directors keep their cool as well. They are trained to do so in medical school and it carries over when they become businesspeople.

Well, the pressure’s on. Our cover story examines the challenges – and the stakes – presented by the Five Star Quality Rating System for Medicare Advantage Plans. One star can add up to millions of dollars in bonuses. Not only that, but high-achieving plans can enroll beneficiaries all year round.

It all comes down to quality. The Centers for Medicare & Medicaid Services notes, “Outcome and intermediate outcome measures continue to be weighted three times as much as process measures, and patient experience and access measures are weighted 1.5 times as much as process measures.”

Executives in MA plans are scrambling, but medical directors who specialize in quality assurance will be particularly challenged, notes Jaan Sidorov, MD, a member of Managed Care’s Editorial Advisory Board. “It’s hard to overestimate the luster of the money from increased payments and the threat of being put on the MA naughty list, let alone having your competition outpace you.” Good luck.

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.