Hindsight is 20/20, but was this predictable? After a year and a half of hard work, a blue-ribbon commission that set out to keep Medicare from running into a ditch itself slid off the road, thanks to deep

ideological divisions regarding government's role in health care. The commmission disbanded without a recommendation — consigning the political hot potato of Medicare to Congress and the presidential campaign.

The Bipartisan Commission on the Future of Medicare, led by Louisiana Sen. John Breaux, was hung up on two issues: quasi-privatization and prescription coverage. Breaux, fellow Democrat Bob Kerrey of Nebraska, and the commission's eight Republicans favored turning Medicare into a clone of the Federal Employee Health Benefit Program. Under FEHBP, federal workers choose health benefits under a defined-contribution system. Two of the seven members who did not come around to Breaux's way of thinking, Stuart Altman and Laura D'Andrea Tyson, agreed that while the idea had merit, it didn't do enough to find new revenue that would keep Medicare afloat when the baby boomers start hitting 65.

The prescription-drug issue was off the table until the last days, when Breaux made an unsuccessful attempt to woo the panel's Democrats, who favored coverage. Breaux's plan would have provided it for people with incomes of up to 135 percent of poverty.

The debate about Medicare and prescription drugs has spilled over into Congress; several bills proposing some form of coverage have been or soon will be introduced. Any and all are opposed by the pharmaceutical industry, which views the benefit of increased demand as more than offset by the threat of deep discounts or price controls. The administrator of the Health Care Financing Administration wants to include prescription coverage in Medicare.

Chip Kahn, president of the Health Insurance Association of America, said while Breaux's competition plan formed a "good framework" for reform, prescription mandates would hurt HMOs' ability to provide affordable coverage.

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.