John A. Marcille

John A. Marcille

The rich ferment of ideas, opinions and causes in managed care today — a source of consternation to some, of stimulation to others — is evident throughout this issue.

Senior editor Michael D. Dalzell, in our cover story, grapples with the issue of treatment protocols or guidelines. Gradually, physicians are coming to terms with guidelines, though of course they see them as valuable when they improve the process of care and as harmful when they prescribe procedures that, on average, might be appropriate for the designated population but inappropriate for an individual. Doctors and physician organizations — the AMA in particular — are suspicious of guidelines promulgated by organizations whose goals they perceive to be minimization of cost, rather than maximization of health. And if they don't "buy in" to the concept, health plans will fall short of their cost-effectiveness goals. (Next month: an article on how disease management programs are getting physician buy-in).

For a discussion of a particular guideline, see the column by senior editor Frank Diamond on the Centers for Disease Control's new guidance on sexually transmitted disease.

Another area of ferment is Medicaid managed care, seen a few years ago as a golden opportunity for HMOs to corner one of the few remaining chunks of the market still in fee-for-service hands. Ferment may be too weak a word for what's going on in the sector.

You want more controversy? Doctors often complain that powerful HMOs practically force them to sign contracts that give the plan too much power. The AMA has come up with a model contract for docs to present to plans. Lawyer Mike Folio analyzes it from both the doctors' and the plans' point of view.

Finally, ferment at the top: Senior contributing editor Pat Mullen reports on reform bills in Congress.

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.