November 2016

Howard Wolinsky
Howard Wolinsky
Scratching the Career Itch Leads To Bigger Reach in Pharma
Timothy Kelley
Climbing the Physician Leadership Ladder: The Top Rung Is Tough and Not for Everyone
Timothy Kelley
Hey, It’s Cool To Be Part Of ‘Hot’ Population Health
Howard Wolinsky
Flexing That PBM Muscle: A Billion Reasons Why It Is a Good Thing
Howard Wolinsky
Keep Patients Healthy (And the Bottom Line, Too)
Howard Wolinsky
Whether you’re stepping up to this position or already hold it and are looking to make a shift, get ready for tumult—and big potential rewards.
Timothy Kelley
Sze-jung Wu, PhD
Qinli Ma, PhD
Patricia Martin, RN, BSN
Andrea DeVries, PhD



Departments
Legislation & Regulation
A court ruling to block a merger in central Pennsylvania could mean more FTC sticks in the spokes of health care system mergers.
Richard Mark Kirkner
ACO Update
Intensive case management and understanding the impact of social needs on health set Medicaid ACOs apart from their counterparts. Meet two organizations that are changing the ACO model.
Michael D. Dalzell
Viewpoint
Their job description may read the same, but in today’s changing environment their influence is on the rise.
Zachary Hafner

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.