John Marcille

John Marcille

Steve Jobs’s death prompted the flood of reflection and rumination that you’d expect when a great person exits. He changed the way we live. Without Jobs, there would be no desktop publishing and we at this magazine would, also, be without jobs.

It also drives home that hoary bit of wisdom that if you don’t have your health, you don’t have much of anything. How many of his billions would Jobs have given for another few quality years of life? How much would you give?

Jobs, you’ll recall, chose alternative medicine for months after being diagnosed with a pancreatic tumor that many experts feel was treatable. He rejected surgery at first and by the time he’d come to regret that decision, it was too late.

There are no guarantees in treating pancreatic cancer or, indeed, much else in life except for taxes, but Jobs should have followed the evidence. This issue of MANAGED CARE certainly does. Our cover story by Michael D. Dalzell, senior contributing editor, is all about the evidence that’s being sifted through as health plans prepare to find out what are essential benefits under the Affordable Care Act.

Our story about PSA testing talks about the evidence the U.S. Preventive Services Task Force looked at in ruling that the prostate cancer detector might do more harm than good, and how health plans may respond to the news. Then there’s our Q&A interview feature, where I interview Mary Barton, MD, vice president for performance measurement at the National Committee for Quality Assurance. Enough said.

Steve Jobs helped to usher in the information age, and the operative word in that phrase isn’t “information” but “age.” Geological ages can last millions of years, but we’re not placing any bets. Still, what Jobs started — the relentless search for, and organization of, information — continues apace, and that means that even more evidence is on the way. We’ll keep you informed.

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.