MANAGED CARE February 1998. ©1998 Stezzi Communications

Managed care reform — a.k.a. the patient bill of rights — is definitely a priority for Democrats, but is it at the top of their health care agenda?

Look for the Senate Labor and Human Resources Committee to give at least equal weight to legislation to protect the confidentiality of medical records. As mandated by the Health Insurance Portability and Accountability Act, if Congress fails to enact such a law by mid-1999, the Department of Health and Human Services must adopt privacy regulations without the benefit of legislative input.

That's not to say the Democrats aren't gearing up for a ferocious fight from the right over President Clinton's plan to require HMOs to tell consumers about how often their doctors have performed certain procedures, whether they have been sued for malpractice and how they are paid.

For some time now, Democrats have known that business would bring out its big guns to fight the Clinton proposal. The U.S. Chamber of Commerce is mobilizing its considerable resources, and the National Association of Manufacturers urged business leaders to wage war on the bill.

Meanwhile, Democrats are determined to show that they are united in their fight. How else do you explain the photo opportunity organized by the White House last month to endorse the administration's agenda? Among those in attendance: Vice President Al Gore, Senate Minority Leader Tom Daschle of South Dakota and House Minority Leader Richard Gephardt of Missouri.

Democrats don't want to cede this issue to the Republicans. Led by Texas Sen. Phil Gramm and Georgia's Charles Norwood in the House, the GOP has introduced its own managed care reform legislation. Gramm chairs the Senate Health Care Subcommittee.

Both Democrats and Republicans are jumping on this issue because of this emerging paradox: More Americans are enrolling in HMOs every day, while at the same time more Americans are expressing their displeasure — and sometimes disgust — at the operations of managed care organizations.

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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.