John Marcille

For the thankful parents who are able to keep their young adult child on their health plan, as well as for the millions who are angry at having had their coverage terminated, there is no ignoring the Affordable Care Act.

Opponents vow to repeal; supporters say, It’s the law, deal. Health insurers too have to deal with the ACA and the many challenges it presents. In our cover story, senior contributing editor Michael D. Dalzell does a wonderful job of explaining how the health system isn’t prepared to treat all of the HIV patients who are moving into Medicaid and commercial plans.

The article kicks off with an anecdote about a patient being moved into a Medicaid plan in which his assigned primary care physician seems to put most of his effort into selling a weight-loss product and whose paper handouts contain ads for a pizzeria.

ACA supporters can take heart that a rough launch does not necessarily mean a crash landing. David J. Brailer, MD, PhD, was the health technology “czar” under President George W. Bush. Brailer, the subject of our Q&A, was charged in 2004 with the daunting task putting every patient’s information into an electronic health record.

“No one then would have guessed how far we’ve come,” he recalls. “We have seen very little partisan bickering, and I think that in part is why it has moved forward so well.”

Our stories about quality-adjusted life-years (QALYs) and next-generation sequencing point to further methodological and clinical advances. They are not just about the bottom line. They are about quality of care and of life. These are profound issues that touch everyone, and with which health plan clinicians must forge some sort of accommodation with patients and providers, not to mention the federal government.

Things are moving fast and we’ll be there to keep you up to date.

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.