John Marcille

John Marcille

Even though physicians are highly trained and generally very intelligent (actually, at the top of all occupations in IQ, according to one study), they face a challenge with which we are all too familiar. There’s almost too much information out there, and not all of it good and sufficient for their needs. Is the therapy they are prescribing actually the most effective, which doctors tend to care a lot about? Is it the most economical, which doctors care less about, but which means a lot to insurers and their clients?

Search for “best practice protocols” on Google and you’ll get 15 million hits. Health plan executives have long pushed a system where the doctor would know the right medicine (actual and metaphorical) for whatever condition he or she faces.

Now, thanks to $1 billion in federal funding, the quest gets even more intense, though the name of the goal changes. Our cover story on “comparative effectiveness research” (CER) begins on page 14. Contributing Editor Martin Sipkoff does a nice job tracking this latest push to get better information into doctors’ hands about which drug, device, treatment, or diagnostic tool is best for specific medical conditions.

“This is information they now lack,” Mark Fendrick, MD, a professor in the department of internal medicine at the University of Michigan medical school and a strong advocate of CER, tells Martin.

With so many federal dollars now involved the situation will hopefully improve.

Brent James, MD, a key researcher at Intermountain Healthcare and one who knows an awful lot about processes of care, says, “I have a hard time imagining why anyone has even the slightest problem with it.”

So do we, but remember, this is health care we’re talking about.

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.