John A. Marcille

John A. Marcille

In Disney's charming "Beauty and the Beast," Maurice — the girl's father — is an eccentric inventor. (Wouldn't you, for once, just love to see a movie show a non-eccentric inventor? After all, some — Jefferson and Franklin, for instance — were practical enough to invent a nation without getting hanged in the process.)

Maurice's cleverness is just a tad out of sync. For instance, he invents a machine that automatically chops wood — just as the world is ready to move toward other sources of heat

Our cover story introduces some former high-powered managed care executives who have hurried toward the possibly greener pastures of e-health. In doing so, they hope to be on the cutting edge of great discovery — not left tinkering, like Maurice, on better ways to turn on gas street lights just as Edison comes out with his bulb.

These talented people decided to leave their six-figure jobs for opportunities to think outside the box; they are not afraid of failure. The story behind the story merits some discussion. It took Managed Care's editors about five minutes to come up with a half-dozen names. Just how many top executives have made this move, and whether that number can be called a trend, is impossible to determine. There is, however, something to be said for anecdotal evidence.

As the story points out, a possible motive for making this jump is a bit easier to pin down. As Michael Barrett of Forrester Research said, "Doctors are unhappy with health care at a time when the Internet beckons. It's got to be irresistible."

Having a sense of adventure adds to the "irresistibility" of e-health. Of course, it doesn't hurt to get results. J. D. Kleinke, a health care economist, isn't nostalgic for fee-for-service medicine, but he sees where the existing system is not making the grade. His e-health company specializes in getting drug information to doctors. (Q&A).

One way or another, e-health is going to be an adventure.

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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.