John A. Marcille

John A. Marcille

One could take the view that by allowing provider-sponsored organizations to become a Medicare+Choice option, the federal government gave physicians, hospitals and other health care providers opportunity and encouragement to assume the responsibility of running a health care system, to integrate the insurance part with the clinical part in a more humane way, and with more consideration of the concerns of providers than most of the older models have offered.

Yes, the feds laid out this great opportunity, and providers dropped the ball. They didn't put up, and so now they should shut up. All that yapping about "taking back the power" (as we put it in a headline last year, and as Senior Editor Mike Dalzell restates in his cover story) — and no action.

To some degree, providers did fail to put up. They should not expect to reap the benefits of provider-run health plans without making some investment. But as Mike discovered, a host of other factors was also at work, and these factors probably outweighed provider investment (although, to be fair, HCFA set a pretty low capitalization threshold for PSOs, to the dismay of existing HMOs).

These factors include the cumbersome nature of setting up a health plan, HCFA's delay in issuing complete regulations, and — the nitty-gritty — the low potential profit margins that many plans would have to accept, particularly in the rural areas where managed Medicare has had little penetration.

We're not going to say that PSOs are a dead issue. HCFA and some others expect a small upsurge in applications in 1999, and we're in no position to contradict. Frankly, we'd like to see provider-operated plans thrive, since the competition with traditional plans would — we like to think — shift a little emphasis toward clinical quality. And the way health plans have performed in the market recently, we know there'll be more than enough pressure for profit. And isn't the tension between these two pressures a defining element of managed care?

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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.