From the Staff of Managed Care

Trade publishing is isolationist in nature. Here at Managed Care, we intently watch the worlds of health, business, insurance, and public policy in our constant endeavor to bring you news, information, and analysis that you can use in your work life. The "great beyond" is brought to you by the general news media, which are well equipped to do just that.

For example, the election deadlock of 2000 got short notice here — appropriately. Some things, however, are impossible to ignore. Some events change everything.

We offer our prayers for the victims of Sept. 11, our condolences to families of victims, our best wishes to the men and women in the military who will respond.

The terrorist attack has nothing to do with what we do here — and everything to do with it. Like the professional sports teams, traders on Wall Street, schools, and businesses across the country who paused to grieve with the nation, we pause also. Like them, we realize that there are more important things than what's going on in our little corner of society.

We too understand that even the language through which we frame the old divisions seems a bit suspect. Sports writers following franchises in competing cities now know how hollow it sounds to say their stars are "at each other's throats." We hear the emptiness in trying to explain the "tension" between HMO executives and primary care physicians.

It all seems somewhat paltry. After all, if we did not know it on Sept. 10, we certainly know now that there are people in the world who want us Americans dead, and who would kill all of us if given the chance.

So, this month's Editors' Memo — if not this month's issue — takes a break from managed care. We'll return in November with comments about the issues in the industry over which debates will continue to be conducted. Those discussions and differences of opinion often lead to progress or reform — the flowerings of free societies.

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.