John A. Marcille

John A. Marcille

Intelligent and articulate. Those are two adjectives I can use to describe Steve Forbes, a man who thinks he should be president of all the country.

I try to get to the National Managed Healthcare Congress every year because many speakers share their knowledge of cutting-edge health care issues. I get to meet people I've only spoken with on the phone, and make new connections as well. There's also the freak factor: famous people with a message or a mission. Last year it was a debate between Jack Kemp and Mario Cuomo; this year, an address by Steve Forbes.

In the last election, Forbes was dismissed as a single-issue (flat tax) candidate. This time around, he has ideas about health coverage, and had the nerve to speak to these folks, most of whom make their living off managed care, about the virtues of medical savings accounts, disconnecting employers from health insurance, and so forth. He received polite applause.

One West Virginia physician told the candidate that the major employer where he lives gave employees a health care allowance much like an MSA. Folks spent it "on new pickup trucks and wardrobes," and at the end of the year, doctors were struggling with a mountain of unpaid bills. Born with a silver spoon in his mouth, Steve Forbes doesn't have a clue about the likely social effects of his programs.

A hundred eighty degrees away from Flat-Tax Forbes lies the movement for a single payer, subject of this month's cover story. There are plenty of good arguments for this funding mechanism, but there are many arguments against it and I doubt we'll ever have a single payer. However, we do need to address the problems that such a system is intended to solve.

But let's say that there's a depression and some wild leftists (no folks, Clinton is a centrist) take power and enact a single-payer system. Death to managed care, you say? I say the recent experience of the Medicare program is a clue as to how the government would treat managed care. Come to mama!

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.