John A. Marcille

John A. Marcille

Every once in a while, we here at Managed Care methodically — sometimes agonizingly — piece together a theme issue in which two or three articles focus on a single topic or on related topics. This usually takes planning, coordination, and insight. Or, we stumble into it, which seems to be what happened this time.

Welcome to California, which, while maybe not strictly a theme, certainly has been accorded the honorific "state of mind" once or twice. (Senior Editor Mike Dalzell, himself a Californian, heartily attests to this characterization.)

Mike writes of the alarming financial troubles plaguing physician groups in the Golden State. Some of the causes are rooted in factors germane to California's signature model of care delivery, the large multispecialty practice — and so while these ills may not befall groups in other states, there are lessons for physicians, health plans, and employers alike. (The flip side of insolvency — that of health plans — is addressed in our States Initiatives column.)

In our popular Q&A feature, meet Walter A. Zelman, Ph.D., head of the California Association of Health Plans. Zelman was, at one time, a consumer-rights activist who advocated a government single-payer system. Gradually, however, he came to see managed care as the great hope for saving money and coordinating care; communicating that vision, though, will require dealing with that pesky image problem.

Our tour then circles around to writer Karen L. Trespacz's lively cover story on the ifs, ands, and buts of consolidation. While this, strictly speaking, is not solely a California story, you'll notice that Zelman makes a prominent appearance here — noting that California, with five or six dominant plans, remains one of the more competitive markets in the country.

How these issues play out in California will, of course, have bearing on the rest of the country. That's why, as theme issues go, this one's not bad. Not that we planned it that way.

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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.