John A. Marcille

John A. Marcille

Much has been said lately about Sept. 11 and subsequent events, helping Americans place what's truly important in perspective. Worried that your sagging stock portfolio means you'll have to settle for a Lexus rather than a Lamborghini? Get real. We are at war with people whose avowed goal is to kill Americans indiscriminately. We are fighting for our very lives, our families, our cherished freedom. Period.

Even Congress, known to indulge absurdity from time to time, realizes (see Washington Watch) that national preservation outranks, say, debate in the West about fees for recreational use of Forest Service land.

Which brings up a point — there will be a day of reckoning when the anthrax scare is over. Think about it: People taking a $52 drug when a $6 product will do the same thing, as Senior Editor Frank Diamond reports this month; people who may never have been exposed to a single spore downing the stuff like candy, contributing to an already nasty problem of antibiotic misuse; and nobody in charge to remind physicians about this — except maybe health plans that have been struggling with runaway pharmacy expenses.

But I digress. Slowly, appropriately, other important issues will creep back onto the national agenda. One is the plight of the uninsured, the ranks of which threaten to explode with the economic downturn and is a public health crisis waiting to happen. As we report in our cover story, health plans have an opportunity to help control the direction of policy debate on this issue now — before it is controlled for them. The events of Sept. 11, if anything, give insurers an opening, given that funding for incremental expansion of existing programs is likely to dry up.

Another ripening health crisis — what happens when the psychological trauma of Sept. 11 expresses itself in increased stress-related illness? As we report in this issue, it's now time to consider how to streamline appropriate access to behavioral health services.

So, what's important?

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.