John Marcille

The history of health care over the past 30 years has included a long list of organizational types that come and go. Some are fads, some are promoted and subsidized by government, some are more talked about than actually undertaken.

Accountable care organizations — ACOs — certainly fall into this category. Our cover story is the latest to join the parade, whose other members include HMOs, PPOs, physician practice-management companies, shared-services organizations, integrated delivery systems, and so on.

In this case, the concept is getting a boost from the federal government under the Patient Protection and Affordable Care Act, which should count for something. Yet as you read the article, you realize that there’s a lot to be done, and while the effort to integrate payers and providers in new alliances promises attractive results, there are many elements to be fit together.

Each participant will have new responsibilities for improving patient care, where each will face serious financial threats, where each will have to create a new internal culture. This is all easier said than done, and I think that is clear in the article, although the authors are upbeat about it.

Jeff Goldsmith, the well-known, perceptive, and loquacious consultant, is less optimistic (see my interview with him), to put it mildly.

Elsewhere in this issue, you will find a discussion of the frustrating management challenges of chronic fatigue syndrome, and a look at how specialty pharmacy management may change — in some cases, is already changing — over the next few years in response to the characteristics of drugs in the pipeline and the increasing need to keep a lid on costs. And we have a slightly whimsical look at what one pharmacy benefit manager is doing to create a bond directly with members.  

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.