John A. Marcille

Sometimes it is all I can do to keep from being totally discouraged about health care finance and delivery. Even the bigger efforts being made to reform the system are often double-edged swords. You want a Patients' Bill of Rights? I'll give you some rights, as long as you sign away your right to an unlimited jury award when there's malfeasance.

OK, that's the patient's point of view. But the industry point of view is reciprocal: You want a cap on jury awards? Give up some other "rights" to patients.

Journalists, of course, make more hay from bad news than good news, for many reasons. Honestly, most good news isn't news, as the many failed attempts to start publications dealing only in "good news" have shown. There's the added difficulty of whom to trust. When there is a disaster, you have no difficulty verifying it, but much good news is really PR, and journalists are paid to filter the jive from the gems.

Yet when I look through this issue of Managed Care, or indeed, any issue of Managed Care, I am somewhat heartened. All is not bleak. This month's cover story by Contributing Editor John Carroll doesn't shy away from the tough issues dividing PBMs from their clients and from patients, but you know, the good news is that the issues are being discussed realistically (unlike, for example, the future of Social Security or the federal deficit or the effects of the recent tax cuts). PBMs, I have no doubt, will be changed by this crucible they are in now, they will survive, and the system will be improved.

I am heartened by Contributing Editor Bob Carlson's look at medical education. After a decade of talk, real efforts are being undertaken to teach med students about how the health care system really works, why guidelines are needed, what "evidence-based" means, and many other aspects of current practice. Even the chart that shows the number of prescriptions rising heartens me — people are getting better care, you can be sure — even if our total spending on drugs is rising faster than other components of the system.

Today, at least, my glass is half full.

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.