John A. Marcille

John A. Marcille

Our cover story this month, deals with the inevitable. Baby boomers are getting older, and there's no reason to suppose that they won't shake up health care with the same ferocity that they've shaken up every other institution they've encountered between Station Cradle and Station Grave. Just how they'll do it is the high-octane stuff that fuels experts' salaries.

Poetic intuition has already led us down this path. Long ago, Robert Browning wrote:

"Grow old along with me!
The best is yet to be
The last of life, for which the first was made."

The line probably resonates more today than it ever did in Browning's time. Boomers are expecting a healthy sunset — or else! Those born between 1946 and 1964 won't, to quote another poet, "go gentle into that good night" but will rather "rage, rage against the dying of the light."

They'll want the best medicine someone else's money can buy. Will managed care be able to provide it? And how?

Just what that medicine will be, and the considerable payment concerns surrounding it, is the subject of a column that makes its debut this month. Check out "Tomorrow's Medicine". Thomas Morrow, MD, vice president and medical director of Matria Healthcare and a member of our editorial advisory board, will discuss the latest biologic medicines, and there's going to be a lot to cover. By 2004, it is expected that there will be 197 such products creating a $40 billion market. The issues could become sticky.

Many issues in contemporary health care have a little or a lot to do with cost, and the cost implications are enormous here. Will they commensurate with the improvement in care? And even if they are a bargain, can we afford them? Or should I say, are we willing to afford them? Perhaps we'll ration them to those who can pay privately?

The nitty-gritty of coverage issues can almost make one jaded about just what's afoot here, technologically. Almost. As Time puts it, medicine will be "utterly transformed." As Browning put it:

"Ah, but a man's reach should exceed his grasp,
Or what's a heaven for?"

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.