John A. Marcille

John A. Marcille

You know the saying about giving someone a fish as opposed to teaching him to fish. Well, a lot of consumers are going to feel that the medical industry has told them to go fish, and forgot to include the lessons. Enter the health plan. Our cover story by Contributing Editor MargaretAnn Cross shows just what consumers are up against. As the story points out, presenting medical management as a benefit to members as opposed to something the health plan is doing to improve its bottom line may make consumers more accepting of the programs, reduce costs to the payer (the employer or government), and help plans to do their jobs better.

I was pleased and gratified to learn that far from abandoning the enrollee, current CDH plans seem to provide enough guidance to push the patient in the right direction. CDH plans are usually described as if they were basically old-fashioned indemnity coverage (deductible, catastrophic, "we'll cover 80 percent"). Evidently, the terminology and the reality are not the same: CDH might not involve prepayment, as in an HMO, but it sure involves managing care.

In this issue, we also look at how hospitals, in a bizarre twist on what has historically been a tense relationship, may be able to talk most freely to health plans about quality improvement.

Our Q&A with Richard Stefanacci, DO, is a big heads-up on what to expect with Medicare Part D come Jan. 1, 2006. Namely, headaches.

We also take note of the potential growth market for retiree coverage and just what the marriage of genomics and predictive modeling means to care and coverage.

There's also a quick look at how one entrepreneurial spirit is offering to manage (at a cost) an expense that's growing: durable medical equipment.

Lots of information to help shore up the bottom line. Now, if that's not teaching someone how to fish....

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.