John A. Marcille

John A. Marcille

Pundits and prognosticators will be pulling apart the 2002 election for months to come, trying to discern the meaning of the results, the voice of the people. Aren't those the same thing? Possibly. In politics, however, 1 plus 1 often equals 3.

The managed care industry will partake in the post mortems as well. Look west, young executive, and you'll see what was once called Measure 23, a proposition that held the promise of universal health care — so long as one did not reside outside a particular universe whose boundaries, in this case, correspond with Oregon's.

Measure 23 was not only defeated, but defeated by about 3-1.

In doing so, voters "took the advice of the health insurance industry," the Associated Press said. How often does that happen?

How did that happen? Perhaps it had something to do with voters recalling (or being reminded) that if it sounds too good to be true, it is. The Oregon plan would have been financed by a new payroll tax of up to 11.5 percent on businesses and an increase in personal income taxes, with the taxes of those paying the top rates rising from 9 percent to as high as 17 percent.

Proponents had countered that those tax hikes would be offset by the savings individuals would see as a result of not having to pay premiums and copayments.

Donald Young, MD, president of the Health Insurance Association of America, was positively crowing.

"Oregonians' refusal to become single-payer guinea pigs repudiates those advocates who would take away people's right to choose their own health insurance," he said.

Advocates indicated they would reintroduce the measure in 2004.

The Oregonian newspaper in Portland reported that opponents spent $5.8 million, about four times the amount spent by advocates.

Defeating this proposal doesn't defeat the problems that led to the proposal: rising health insurance premiums, pharmaceutical costs and, oh yes, high rates of uninsurance. Can the various health care stakeholders get these under control without government intervention? Stay tuned.

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.