June 2016

Americans’ tolerance for waiting is disappearing fast, and the technology that enables digital encounters is getting better all the time.

One of the problems deals with uneven coverage among different health insurers. Doctors want more clarity.

Susan Ladika
Doctors have pretty much made their peace with retail clinics for problems like sinusitis and routine vaccination. But they aren’t ready to concede care for chronic conditions to the retailers.
Robert Calandra
House calls for the frail and chronically ill are making a comeback. But CMS and private payers are still figuring out how to make the economics work.
Joseph Burns

Insurers need to think strategically to ensure that beneficiaries remember to keep going back to their app for health information.

Jan Greene

The insatiable American appetite for convenience is spreading to health care, says Ateev Mehrotra, an expert on retail clinics, telemedicine, and other convenient care delivery models.

Interview by Peter Wehrwein

Nursing brings her into intimate contact with blood, pain, suffering, and freighted issues of life and death. But in her book, Theresa Brown uses a deft, writerly touch to delve into the more prosaic aspects of American medicine—the doctor–nurse dynamics, the hassles of charting, and financial incentives that skew care toward tests and procedures.

Interview by Peter Wehrwein

Legislation & Regulation: Campaign 2016

Selling coverage across state lines dusts off an old idea that has new legs.

Richard Mark Kirkner
Tomorrow’s Medicine

Revolution isn’t too strong a word to use about what’s happening with this technology.

Thomas Morrow, MD
Richard G. Stefanacci, DO
Plan Watch

The info comes compliments of Aetna, Humana, and UnitedHealthcare.

Joseph Burns

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.