John Marcille

John Marcille

We’re all time travelers. It’s just that we only move forward and, not to get gloomy, for only a relatively short span. We don’t go back. If we could we might — out of curiosity — leap 3,800 years to when Babylon’s King Hammurabi issued his code for physicians. This is the subject of our story on page 30. That story itself is a time traveler. We published it in 1997 and it remains one of our best-read pieces on the Web, so we’re serving it up in print again.

Most things in this world don’t last long. For instance, our sister publication, Biotechnology Healthcare, was launched back in 2004. This high-quality publication highlighted extremely interesting articles and departments, as evidenced by reader feedback and expert writers’ contributions.

However, as I am sure you have read, almost all magazines are suffering declines in advertising pages. We have regretfully suspended publication of Biotechnology Healthcare.

Even so, it will not disappear entirely. It is now a regular feature in Managed Care, beginning with this issue. And why not? Management of biotech drugs is of increasing (I would argue crucial) interest to our readers.

Which brings us to our cover story by contributing editor Joseph Burns. He investigates what the Institute of Medicine calls the “learning health care system,” one that’s continuously focused on process improvement.

The idea is to create a model that systematically eliminates waste. The good news is that we already have the tools. In fact, some corners of health care do it quite well.

The trick now is to make the whole system follow suit. Such an accomplishment would be hailed for a long time. Maybe not as long as Hammurabi’s Code, but why not shoot for the stars?

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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.