John A. Marcille

John A. Marcille

The biggest threat to managed care as now practiced may be this new scheme, defined contribution. Even more than the Patients' Bill of Rights, this is a movement that could shake the industry. But as seen in our cover story, the term "defined contribution" covers a range of financing and delivery mechanisms.

In pure defined contribution, the employer hands the worker some pretax earnings and says, buy yourself some health care. That model isn't seen too often. In other models, the employer retains some control, but care often is not prepaid, as it is in an HMO.

We at Managed Care understand employers' desire to make workers feel the pain of health care premium inflation so that they will have an incentive to moderate their consumption, but we are highly skeptical of "solutions" that would drive healthy young workers into low-cost plans and herd sicker folk into other types of plans. For generations, employer-sponsored health coverage has minimized the variation in workers' out-of-pocket costs, and nobody ever warned today's older workers, who dutifully subsidized their elders' care in the past, that we would cancel the deal when they started to need care for more serious conditions.

You will hear people call these new plans "consumer-driven" and call the movement "consumerism." It is true that the new systems require the patient to make decisions, and there may be much good in that. But "consumerism" and "consumer-driven" imply that the impetus for these systems came from consumers. That's untrue. Consumers want choice of providers, and the Patients' Bill of Rights began as a consumer bill. But the defined contribution movement is being forced on workers by employers. And there are serious concerns about whether it will result in better health care — or worse. It certainly will be a challenge to HMOs.

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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.