John A. Marcille

John A. Marcille

In Corporate America, customer service has moved to the top of the business plan. That's not to say customer service training has improved — how many times have you dealt with some surly 19-year-old when trying to return something to a store? — but the idea has gotten traction in theory, if not in execution.

The managed care industry, now somewhere in the age range of those 19-year-olds, could easily have demonstrated the same level of arrogance. Employers pay the bills and demand low premiums — who cares what the people want? Yes, it can be argued that health plans could have remained rigid until political pressure forced them to examine their relationships with members. But savvy plans have come to recognize patients, not just employers, as customers, ever willing to walk away when service is lousy.

The result is illustrated in this month's cover story. The industry is changing, in terms of business models and product offerings. Call it consumerism, member self-management, or whatever, but the direction clearly is to give members more say in their care. Now, it's one thing to recognize that "The customer is always right." It's quite another to deliver a product that satisfies customers without letting them run your company into the ground. Health plans are getting warmer with members, developing administrative and care-delivery vehicles to make that change easier, but behind their smiles is a firm resolve to make members more responsible for the consequences and costs of their actions.

Where does this leave physicians? As patient advocates, physicians might be expected to welcome this development. In helping patients make better health care choices, physicians have a chance to raise their stature and clout in the eyes of health plans.

Our Q&A interview, too, hits on this theme of consumer independence. Tom Miller, director of health policy studies at the Cato Institute, makes a strong argument for disconnecting insurance from employment. Whether you agree or disagree with his reasoning — and our role is not to promote an agenda but merely to be a forum for ideas — it's provocative reading.

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.