John A. Marcille

John A. Marcille

We know that this may be the most inflammatory issue that we have ever produced, between "alternative" medicine on the one hand and physician unions on the other. Our purpose is neither to upset nor to coddle you. We just want to keep you informed. Still, as they say, a little knowledge is a dangerous thing.

Our physician readers may be irked by what they may perceive as our endorsement of alternative medicine in the cover story. We don't promote it. Rather, Senior Editor Mike Dalzell points out that health plans have made the decision to cover some of these services, mostly for marketing reasons, and he describes the need to somehow integrate them with traditional Western medicine in a manner that is clinically defensible.

Likewise, we expect some health plan executives and physicians to be appalled by the inflammatory statements of Robert L. Weinmann, M.D., president of the Union of American Physicians and Dentists. Weinmann calls it as he sees it — and he doesn't like what he sees. He is merciless in attacking commercial insurance and managed care and even takes a swing at the American Medical Association.

Still, doctors and HMO executives are going to learn some things about the union movement that they didn't know. They're going to see possibilities that they hadn't seen before. Agree with Weinmann or not, he's sharp and not to be ignored.

Even our medical ethicist, John La Puma, M.D., independently weaved into his own piece some theses that appear elsewhere in the issue: He argues that failure to treat obesity (not just obesity-related disease) is "criminal," while at the same time seeing a great and expanded role for managed care in "lifestyle" areas that sometimes include alternative therapies such as acupuncture, massage, and chiropractic.

Both unions and "alternative" medicine are issues because of faults in the system. Will they improve it or substitute their own faults?

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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.