John A. Marcille

John A. Marcille

If the White House indeed takes on tort reform this year, it will be interesting to see if any meaningful legislation results and what effect it might have on health care. Doctors in this litigious age tend to practice defensive medicine, and that means more use of expensive imaging technology — as our cover story makes clear.

"It is a conundrum," says William Corwin, MD, medical director for utilization management and clinical policy for Harvard Pilgrim Health Care. "Where does your judgment and confidence in your diagnosis preclude your concern about the judicial system? Doctors tend to err on the side of ordering the test. What they need to do is pause and ask themselves, Will ordering this $1,500 test change the way I manage this case?"

The story does not lay all the blame at the feet of physician, of course. The problem of imaging costs is complex, and author Maureen Glabman describes that complexity — and the techniques of plans that do a good job on this — with aplomb.

And while Harvard Pilgrim, along with every other insurer, has imaging problems, it apparently has no image problem, as our story about that company's recent fortunes makes clear. Much of the credit for Harvard Pilgrim's amazing turnaround goes to CEO Charles Baker, whose hands-on approach includes seeing how the claims process works for his own family. "I have a wife and kids, and we have the same things going on as everybody else," says Baker.

Well, not exactly the same things. A lot of families may include parents who have made a name for themselves in business. But how many have a father who is now being mentioned as a possible Republican candidate for governor of Massachusetts? The business community, says the Boston Globe, "adores Baker's braininess," and Democratic politicians "respect it." Interesting.

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.