John A. Marcille

I don't want to sound naive, but a fundamental characteristic of democracy is that we work out solutions to problems in such a way as to benefit the entire society, meanwhile protecting the rights of minorities.

When you read Peter Wehrwein's cover story on legislative intrusion into health care insurance, you'll get a broad picture of the forces at work on Congress and state legislatures. We often see these debates as "us vs. them," "doctor vs. HMO," "patient vs. plan," rather than look at what each category of legislation does for, or to, health care and society as a whole.

And often enough, things work out for the best. We're not just talking about whether Massachusetts or Virginia will lose a military base. We're talking about decisions that can raise or lower the standard of health care for all of us and our children, and just as easily raise or lower our standard of living through their effect on health care costs.

Until recently, there was no way a consumer or purchaser could compare plans except for price. Now NCQA, FACCT, JCAHO and others are attempting to measure quality. Under fee-for-service medicine, quality was seen to be referrals, tests and drugs on demand. Now we're looking at outcomes and at processes. Eventually employers won't support plans with too many readmissions of newborns; minimum-stay laws will be unnecessary. But those and other recent laws, while they may increase costs slightly in the short run, send a needed message to insurers: Americans want high-quality care and compassionate treatment by plan as well as physician.

A little legislative intrusion, then, has its uses. Where legislators are working against the general good, though, is in kowtowing to specific providers, be they chiropractors, acupuncturists or ob/gyns. This is a bad side of politics, one we see far too often. Special interests, not the public's fear of gag rules and premature hospital discharges, are the real enemy.

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.