John A. Marcille

John A. Marcille

Brace yourselves. The election sprints toward its finale and it seems as if, regardless of the winner, the country will enter a dynamic period. Issues, foreign and domestic, could reach a point where a course is chosen that breaks with the evolutionary progression that has gotten us here. That's domestic, as in health care.

Is managed care analogous to an inventor in the 1870s laboring over a system by which gas street lights might be turned on automatically just as a figurative light bulb goes off over Thomas Edison's head? Our cover story offers some hope for the managed care traditionalist. Contributing Editor Martin Sipkoff reports in detail on the argument, which I find persuasive, that allowing people who are sickest to pay less for drugs is not only humane, but makes good business sense. This could be a great step, but who can be sure?

In the Aug. 23 issue of the New Yorker, Adam Gopnik — reviewing recent books about World War I — discusses the struggles that we amateur and professional gazers into crystals confront.

All these historians find themselves contending with the issues of historical judgment: how much can you blame the people of the past for getting something wrong when they could not have known it was going to go so wrong? The question is what they knew, when they knew it, if there was any way for them to know more, given what anyone knew at the time, and how in God's name we could ever know enough about our own time not to do the same thing all over again. Or, to put it another way, are there lessons in history, or just stories, mostly sad?

We can only end as we began: with a warning. Brace yourself.

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.