John Marcille

John Marcille

Spring fever must have settled in early around here. You may notice two baseball references in our magazine and another in our online blog. The thought of baseball can warm the heart on a cold, snowy day. The blog item refers to a new forum where clinical executives can gather, kind of like the bar depicted in the TV show Cheers, where Sam Malone, a former Red Sox pitcher, served up various spirits to Boston patrons.

The first mention of baseball in this issue appears in our cover story. Contributing Editor Joseph Burns refers to the movie Moneyball in discussing why health plans are increasingly contracting with narrow networks of providers. Health care is like baseball, says Brett Morris of Health Net of Arizona, because officials like Morris are always trying to put together the best teams of providers, the “free agent” physicians and hospitals who can deliver high-value, low-cost care.

Not every provider can or should make the cut. Not in an era where the emphasis is on accountable care and patient-centeredness. As the consultant Paul H. Keckley, the subject of our Q&A, points out, clinical executives at health plans now have the hardest jobs, and are often the only voice with clinical training and experience in the room. They’re managers in every way.

Which brings us to our second baseball reference in a story announcing the launch of the Medical Directors Forum (MedicalDirectorsForum.com), the same one mentioned in the blog (www.managedcaremag.com). The analogy used is of baseball players sitting around discussing the art of hitting.

The online forum is a place where medical directors can talk with peers about many medical management topics. It’s also a source of governmental and many private companies’ guidelines that clinical executives sometimes have to consult to do their jobs. It’s somewhere they can go to get the encouragement and pick up a few pointers on matters of mutual interest.

Did you hear? Pitchers and catchers are going to be reporting any day now.

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.