Donald M. Berwick, MD, is President Obama’s nominee for administrator of the Centers for Medicare & Medicaid Services (CMS) and certainly no stranger to the readers of MANAGED CARE. We have interviewed him many times over the years. In a long Q&A in 1999, Berwick — the president and CEO of the Institute for Healthcare Improvement — offered some insight into what he considers the best in managed care, specifically citing, among other insurers, Kaiser Permanente and Harvard Pilgrim Health Care.

He told us back then: “In our work in the institute, we are always looking for the best we can find. We search the country and the world for the best care of back pain we can find, the best asthma care, the best intensive care units or the best obstetrical management. It is exceedingly rare that, after picking a topic and searching hard, we don’t end up with some of the famous and important managed care systems in the country on our list of the best we can find. I think it’s no accident. I think they’re the places that had the leadership and information and systems. The best of managed care is often the best we have.”

And we believe that the best of our health insurers and administrators still have top-flight leadership and information and systems.

Berwick faces a tough confirmation hearing because some Republicans believe that he favors rationing.

Two of our editorial board members give Berwick high marks:

“Donald Berwick is without question one of the most respected leaders in health care in the United States and the world,” says Thomas Bodenheimer MD, professor of family and community medicine at the University of California at San Francisco. “He changed the entire paradigm of quality improvement with a New England Journal of Medicine article about 20 years ago, arguing that many medical errors are the result of system dysfunction rather than individual failings.”

Richard Stefanacci, DO, the director of the geriatric health program and Center for Medicare Medication Management at the University of the Sciences in Philadelphia, says that he has “always appreciated having a physician in the lead at CMS. I’m sure that he will surround himself by special advisers with geriatric expertise, since his training is at the other end of the spectrum.”

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.