John Marcille

John Marcille

You can’t blame them, really. You can’t fault state legislators for looking for fiscal relief from the foundations created when not-for-profit health plans become for-profit entities. The organizations are expected to dispense around $450 million a year to widely diverse causes that fall under a broad — very broad — description of a public health effort.

Hey, said then Gov. George Pataki in a New York minute, let’s use that money to increase the salaries of state health care workers. And he did, taking $1 billion generated when Empire Blue Cross & Blue Shield became a for-profit company.

Sure there were protests and even a lawsuit. Yet, according to our cover story on page 16 by contributing editor Maureen Glabman, when the dust cleared, Pataki got his and the foundation was left with a paltry $50 million. Many readers will remember how it all went down.

Other states are using different means to dip into foundations because it’s clear that help from the federal government will not be coming. The administration projects that the federal deficit for 2009 will be a record-breaking $482 billion. Meanwhile, problems in the mortgage industry persist while the price of crude oil fluctuates. What’s a responsible lawmaker to do? Just say no?

The Pataki raid represents two main problems with foundations: They sometimes lack direction and too often find themselves prey to government overseers more than willing to give them that direction. Meanwhile, lost in the headlines is the original purpose. The foundations were meant to provide funding and initiate programs in their communities to compensate for years of foregone state taxes that allowed the not-for-profit plans to grow.

The foundations have mostly stuck to their mission, but you have to wonder, for how much longer?

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.