John Marcille

It’s a fact that the nature of managed care as it has evolved, with the HMO or some other insurance (or sometimes just administrative) company in the position of paying for everything but often not having the last word on what’s being done in the clinics, has frustration built into it. Why do these folks not pay more attention to expert guidelines? What about those conflicts of interest between being a surgeon and owning part of a specialty hospital devoted to surgery? And on and on.

And yet these plans have had a positive effect on restraining costs and improving care. As we know, the two often go together.

One of the big cost drains, we have recently come to recognize, is a consequence of the fragmented nature of our delivery system: the imperfect transition from one care status to another, and you know I’m talking mostly about hospital admissions and discharges. Insufficient information accompanies the patient; tests are duplicated; the patient’s overall drug picture isn’t monitored; and so on. All too often, the result is a hospital readmission that might have been avoided.

Managing editor Frank Diamond goes into all these in detail in our cover story, but the most interesting part is what insurers are doing to smooth and improve transitions of careGeisinger Health Plan, UnitedHealthcare, the Regence Group, and elsewhere.

Health plans, which know a lot about case management and have enormous data sets, are in the forefront of improving these transitions.

And let me point out that our Q&A subject this month, Peter J. Pronovost MD, PhD, has a lot to say about what happens within the hospital. His systems for reducing errors and the spread of disease have had a profound positive effect on the care that patients receive. Fewer diseases and errors, less cost. 

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.