Managed Care Industry Change Looks to Outcomes, Not Process

John Marcille

I’m really excited about this issue. Major change is afoot in the managed care industry, and we are writing history’s first draft. Take our cover story. For many years we’ve been reporting on pay-for-performance programs, and I always felt that, as well-intentioned as proponents of these efforts were, something was amiss. Does it really matter if a doctor performs well on process measurement if there’s no improvement in morbidity and mortality? Yes, process is vital, but only if the fruit of such process leads to good results. In the real world, outcomes, not the number of pap smears or glucose tests, are the bottom line.

Then look at the article about how the National Comprehensive Cancer Network, an alliance of 21 top cancer centers, has become the agency that Medicare and health plans are turning to in making coverage decisions about expensive oncology medications.

Our Q&A with David Nace, MD, is another example of real change a-coming, this time thanks to the Affordable Care Act (unless, of course, that law is struck down by the courts or a legislative fusillade). Nace, the vice chairman of the Patient-Centered Primary Care Collaborative, says that medical home offers a blueprint on how to make the new focus on providers work.

Of course, often what’s old is new, and vice versa. How many times have we published articles about the importance of adhering to accepted best-practice guidelines? Our report on the opportunity for better management of heart failure makes the case again, and more convincingly, by showing how little expenditure is needed for a good return on investment.

Please, let me know if my hopeful view is warranted.

Career Opportunities

HAP, a subsidiary of Henry Ford Health System, is a nonprofit health plan providing coverage to individuals, companies and organizations. This executive develops strategies to meet membership and revenue targets through products, pricing, market segmentation and advertising.  Aligns business among Business Development, Commercial Sales, Medicare and Public Sector Programs and Product Development. Seeks to enhance and be responsible for business development and expansion through the development of an effective product portfolio, strong interpersonal relationships and service excellence.

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