John A. Marcille

John A. Marcille

Some experts have long suggested that we should be able to buy health insurance the same way we buy car insurance. This maxim touches on the power of free markets and free will to transform a system. The mindset is one of knocking down barriers, in other words.

However, one of the elements of buying car insurance is that it's very difficult to not buy it. For instance, in my state (and, I hope, all states) you can't register a car without first showing that you have insurance. I suppose that you can allow that insurance to lapse and continue driving, hoping not to be caught. One can also save money by not declaring all of his income to Uncle Sam. Greed does not always show up at the local convenience store or bank dressed in a ski mask and demanding the loot. Greed often takes the passive voice of "forgetting" about those under-the-table earnings or letting the car insurance lapse.

Contributing Editor Martin Sipkoff's cover story on the potential rescue of those without health insurance touches on many facets of the issue, among them the fact that a lot of the uninsured have chosen to be uninsured. Should they be allowed this option? I've noticed that position on the political spectrum is no guarantee of where someone stands on this.

An America in which all have health insurance shouldn't be a matter simply of either government largesse or corporate suavity. Hold on there, one might say. People do have a right to decide whether to drive, thereby dodging car insurance, and driving, altogether. True. All of us, if given the choice, would decide not to get sick. Now, if only that were our call.

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.