Just how much responsibility and cost consumers are willing to carry when it comes to health coverage is the focus of this issue — September 2003. At it happens, 10 years ago — September 1993 — Managed Care looked at the consumer's role in grading physician performance. Cost borne by the enrollee wasn't an issue then; employers bought HMO coverage and copayments were minimal.

Measuring patient satisfaction was becoming a big deal, and I wrote our cover story for that issue on ways that physicians might improve their consumer ratings, so to speak. A small percentage of a capitation payment might ride in the balance.

Perhaps I should have labeled this page "Department of The More Things Change...." Patient satisfaction isn't heard as a term so much any more, but if you look at the various proposals for consumer-directed health care, it becomes obvious that enrollees are to be allowed, if not forced, to vote with their feet. If I were running a hospital or a physician group, I'd be paying attention.

Back in '93, the Clinton plan was causing a lot of commotion. In that cover story, I wrote:

"Should managed competition and a uniform benefit package become law, managed care organizations will have to compete on the basis of cost and quality. Plans that provide high clinical quality to satisfied patients will score higher on the much touted national 'report cards' for health organizations, which could allow them to charge higher premiums than competing plans, and be able to offer you higher payments."

That was then, and the specifics of that proposal are dead. But just last month, health economist Alain Enthoven told us that he hasn't given up on managed competition, that rising costs will force the system to finally try his way.

Those report cards — brought to us by the folks at the National Committee for Quality Assurance — have been with us for some time now. We are still trying to sort out just what their effect may be regarding how much health plans charge, and what they pay physicians.

In that article, 10 long (or is it short?) years ago, Alan L. Hillman, MD, MBA, currently chairman of our Editorial Advisory Board, questioned just how much patients can do.

"Certainly no one thinks that patient satisfaction fully reflects quality, because you can have doctors who have terrific interpersonal skills, great amenities, and perfect office hours who bumble and fumble their way through the technical aspects of medicine and make all kinds of mistakes," Hillman said in 1993.

"You're going to have to distinguish between the patients' perception and what actually happened. Patients are not qualified to make judgments about the technical quality of their care."

Even back then, though, some people insisted that one need not be an expert to be able to make many health care decisions.

"What I've read and what I've experienced myself suggest that patients are probably a pretty good source of information about medical outcomes and that patients tend to be reasonably appropriate in terms of linking satisfaction with outcome," said Cary Sennett, MD, then an official with U.S. Healthcare (this was before the merger with Aetna).

Maybe we have moved on. Ten years ago, consumers were seen as hard-to-pin-down databanks that health plans might mine to judge how much to charge for benefits, and to pay physicians. These days, information flows both ways. — John Marcille, Editor

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.