John Marcille

John Marcille

High-deductible plans are taking off; 2008 will be the breakthrough year. Or, they are a disappointment, a fizzle, a nonstarter. Yes, over the past few months there have been headlines that go both ways. I have no crystal ball, and I have no data that would encourage me to make either prediction. What I do know is that insurers are adaptable, and they will offer whatever the market demands.

Payers — companies that buy health care and/or health insurance for their employees, are demanding relief from escalating costs. I demanded relief from my home heating oil supplier the other day and she laughed at me.

Insurers don't have the luxury of laughing at customers, but they have to deliver good products that will do what the customer wants, even if it isn't what the customer initially thinks he wants. I don't take my car to the shop and say that I hear a roar and you should fix the muffler. I say I hear a roar and what can you do about it? In my experience it's always been the muffler, but it could be something else.

Similarly, with health care, high deductibles save the payer money, but for him to prescribe them (replace the muffler) specifically and without exception may be unwise, which leads us to this month's cover story on the latest developments in the debate over whether high copayments lead not only to a reduction in unneeded or optional care but also to a reduction in necessary care, resulting in worse outcomes and overall higher costs.

Plans owe it to payers and patients (if not to the imaging centers that do all those MRIs) to get the evidence and try to ensure that the customers design their health benefit so as encourage what they really want: the right care (what's needed) at the right time (to keep a condition from worsening) at the right place (a provider that does a good job at a fair price).

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.