John A. Marcille

John A. Marcille

Everyone reading this has a better life than the vast majority of people who have ever lived. The most impoverished among us has a standard of living that the kings of old could only dream about. There's a saying in some countries that goes something like this: "If you have to be poor, be poor in America."

Of course, you'd never know that by looking at the faces that pass in the street or the murky dissatisfaction that roils our inner lives.

Recent books dwell on the issue: Why are we so unhappy when, by any objective and historical standard, we have no right to be? Others can try to answer that one, but we'll just make this observation.

This unhappiness, this dissatisfaction, may be the reason why we constantly strive to make things better, to test and then retest solutions to problems.

Like narrow networks, the subject of our cover story. Once upon a time managed care looked to these networks as part of the cost-containment solution. But consumers didn't like the lack of choice. So the networks broadened, at a time when premiums were static. Now, consumers are not satisfied with rising copayments and premiums. Narrow networks return.

As the story points out, this time information technology is a factor. "After all, physicians in the early '90s could not get online and access a database showing how their prices and practices measured up to those of their colleagues," the story notes. Also, employers can offer more than just narrow networks, thereby reducing the impetus for consumer backlash.

We hope. But it's not in our unhappy nature to just let well enough alone.

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.