Frank Diamond

Managing Editor

Stories about underdogs (David and Goliath, Rocky, the 1969 Mets, the 2008 Barack Obama) are as much about overconfidence as they are about confidence. Yes, the challenger is scrappy. The favorite, on the other hand, needs just enough hubris to make his or her downfall ensure that the lesson resonates with every would-be David and Goliath — and in its entirety because we all have a little of each in us.

Many insurers want to participate in health benefit exchanges, one of the bedrocks of the Affordable Care Act. We’ve been following this at Managed Care. See, for example, here (, here (, and here (

Of course, in the exchanges, insurers won’t face just one antagonist but a whole marketplace full. It might be enough to give them pause and, in fact, it may have. They’re still confident, though, according to a recent survey by KPMG, the audit, tax, and consulting company. Take a look:

Assuming your organization’s participation, how confident are you in your management’s ability to successfully participate in an exchange?


Number of organizations


Not at all confident



Somewhat confident






Very confident



Not applicable



I suppose that’s the attitude an organization needs when it’s about to step into the unknown. Perhaps it’s because they feel they have implementation under control.

By when do you expect your organization to start marketing and delivering products that are consumer-focused?

We are doing this now


Within 6 to 12 months


Over 1 year from now


Don’t know


Not applicable


As KPMG notes, success will mean “transforming their marketing efforts from a business-to-business focus to a business-to-customer focus.” That’s not the only concern and while insurers — and about two thirds of KPMG respondents are commercial health plans — may be confident, they’re not blind to the challenges.

What is the biggest challenge in building out a customer-centric organization?



People/skill set




Senior level buy-in




All of the above


None of the above


That 58 percent say “all of the above” to this question might signal, again, the level of effort and focus being displayed. Or, to a more skeptical viewer, it might — just might — suggest that organizations are scurrying about in a bit of a panic. Please, weigh in.

Frank Diamond, Managing Editor

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.