John A. Marcille

John A. Marcille

Nobody likes a braggart. We're all weary from the hype that has come to be expected from everyone from car salesmen to movie studios to presidential candidates. We're more in danger of tuning out than of being taken in.

Yet there should always be a respectful audience for craftsmen who take quiet pride in their work. All of which is a roundabout way of saying: We're proud of this issue. From the cover story to the monthly departments, our October issue is an easy-to-use survival guide for the busy health plan executive. Why? It's the writing — specifically the work of our contributing editors: Martin Sipkoff, John Carroll, and MargaretAnn Cross.

The next big thing? Better make it things. See what Sipkoff has reported about pain management. The article overflows with information on how this affects you, and what your approach might be. Or see what Cross describes as a trend among HMOs to restore profit margins by charging deductibles for basic services. And just what's up with Maine and the push there by reformers to have universal coverage? Carroll outlines just how much of a chance this has of flying — and spreading.

But the good writing doesn't end with our contributing editors. Look at our Tomorrow's Medicine department and see the important coverage decisions that must be made regarding an acid copolymer for treating severe vesicoureteral reflux. We're proud that the author, Thomas Morrow, MD, sits on our Editorial Advisory Board.

Ed Silverman is a business writer for the Star-Ledger of Newark (N.J.) and a frequent contributor. He spots trouble on the horizon regarding the uneasy relationship between health plans and hospitals.

Lack of space prohibits me from continuing, and it's self-serving for me to invite you to see for yourself just how interesting this issue is. Being self-serving doesn't mean it isn't true.

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.