John A. Marcille
EDITOR'S MEMO

John A. Marcille

In health care, as in our whole society, many interest groups battle for position. These groups — patients, doctors, hospitals, health plans, long-term care facilities, drug and device manufacturers, and all the others — mostly seem to have reasonable arguments when they seek business and try to influence legislation and regulation in Washington and the states.

With the prescription drug reimportation act, which may eventually prove to be comparatively small potatoes on the vast health care buffet, we saw respected players promote their positions and, as Managing Editor Mike Dalzell notes in his story, we should look for post-legislation developments in the rulemaking phase. There could even be an attempt to use state legislation or regulation to limit the effectiveness of the federal act.

It's part of the American way: Keep fighting for advantage. As I write this, a soon-to-be-textbook example of this is underway in Florida, as this incredible presidential election grinds on.

I feel sorry for the elderly who depend on Social Security and Medicare, and the many uninsured younger people. Per-capita costs for drugs have gone up dramatically, and many people don't have drug coverage. In the midst of prosperity, we've changed the rules for these folks. What's right is the great success of the pharmaceutical industry in bringing to market drugs that truly prolong life and reduce the need for surgeries and hospitalizations. What's wrong is that we've been quietly cost-shifting: relying on drugs to improve health and control other costs in the system, without addressing the underlying insurance structure that places a growing burden of drug costs on those with the least resources.

Drug reimportation is a curious and limp attempt to deal with the greater issue. It's not clear that reimportation will actually have much effect when it happens, but it is definitely a politically safe response to rising drug costs. It's an important matter of public policy, not just a market issue.

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.