John A. Marcille

John A. Marcille

It's our nature to experiment with the world and, after that, to experiment with the systems we've created to live here. Such experimentation readies the stage from which the great leaps of imagination and technology spring.

This month's cover story on direct contracting is really a look at some of the experimentation constantly going on in managed care. As most of the experts we talked with point out, direct contracting really can't become a nationwide system as long as small employers are discouraged from forming insurance purchasing consortiums. Even if that should occur, the safe bet is that most employers would still rather avoid the headaches.

Yet, the experiments go on — most notably in Minnesota, where the Buyers Health Care Action Group claims to have been contracting directly since 1997. Has it? One of our sources swears that if you squint your eyes and tilt your head a bit — experiment with the view, if you will — the BHCAG looks very much like an HMO.

Despite this criticism — who knows? Maybe, a few years down the line, thanks to what's going on in Minnesota today, someone will have figured out how to make direct contracting work everywhere and a whole new system will be launched.

The experimenting we do at this magazine also prepares the way for major new endeavors. This month we unveil one of those as we solicit, for peer review, scientific studies that examine clinical and financial aspects of managed care. In preparation, we have expanded our editorial advisory board and compiled guidelines for submitting papers. (See "Managed Care Launches Peer-Reviewed Section")

Guided by Alan L. Hillman, M.D., we will begin to publish reports of original research on a range of topics. This modest step is taken in the same hopeful, but mostly hidden, spirit in which so many scientists approach their daily struggles: to understand and, perhaps a little, to change the world.

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.