John Marcille

John Marcille

Isn’t it encouraging to hear more evidence of the success of consumer-directed health care? By which I mean the idea of making members put some skin in the game, as the overused metaphor has it.

Just what success do I refer to? Well, there is that report from the Center for Studying Health System Change, which tells us that 20 percent of Americans went without needed medical care last year, most of them blaming high cost.

Some employers push those high-deductible “consumer” plans on the stated theory that people will choose more cost-effective care options and will forego unnecessary care. But it stands to reason that they will forego necessary care too, if their out-of-pocket cost is too high. Let’s face it: Health care isn’t cheap, and now neither is gas. Readers of this journal are not exactly economically representative of median America, where folks might have to choose $4.50-a-gallon oil over $4.50-a-pill maintenance drugs because if they can’t get to work, they can’t buy anything at all. Median (not per-capita) household income was $48,000 in 2006. I don’t have to tell you that means half the families have incomes below $48,000.

The New York Times reported that the lead author of the CSHSC study suggested that it wasn’t just high-deductible plans that led to the voluntary denial; it was likely, he said, that the cost of care has finally gotten just too high for a lot of people. Guess I jumped the gun, blaming it on plan designs with high out-of-pocket costs. Or was I just being tongue-in-cheek? You decide.

Health plans do what they can to keep a lid on costs, but it ain’t easy. In this issue, we discuss the need to ensure adherence to specialty pharmaceuticals so as to get the most bang for the buck and a Leapfrog initiative on hospital length of stay. But we also take note, in our cover story, of a trend that could be bad for costs — physician-hospital integration — while at the same time offering the prospect of more highly coordinated care.

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.