John A. Marcille

There's a charming little children's book called Pierre, written by Maurice Sendak in 1962. In the story, pint-sized Pierre could say nothing but "I don't care" whenever his parents spoke to him. When a hungry lion threatened to eat Pierre, the crumb crusher's comeback was "I don't care." Pierre became the lion's dinner. The moral of this story? Care!

A similar tale could be written about obesity. Obesity is a ticking time bomb, in terms of both health and health care expense. But the reaction of the public and of the health care community has been just like that of Pierre: "I don't care."

Physicians complain that once patients leave the doctor's office, all the advice is cast aside in favor of a comforting late-night bowl of ice cream. Plenty of evidence supports that, but there's equally embarrassing proof that physicians aren't expressing the message effectively or to enough patients.

Health plans, too, are culpable. Losing weight is more than a matter of will power; obesity is a complex, chronic condition, and fighting it effectively requires psychological support and skill training. It's a touchy-feely side of medicine whose benefits are hard to quantify, so few plans are willing to invest in it.

No question, this is bigger than any health plan. It's a public health issue — and as such, it is American health care's biggest failure. But the public finger-pointing among the principals in health care has distracted them from the objective: Reduce the incidence of obesity, a leading cause of premature death.

Mike Dalzell's cover story explores how — and why — health plans can and should take the initiative on this, in conjunction with physicians and public health. Without that collaboration, the market will find its own way. The extreme scenario: Frustrated with the cost caring for "train wrecks waiting to happen," employers could divorce themselves from the benefit process and move toward a defined-contribution system.

We have beaten some of the most dreaded illnesses in history. If everyone would just care, we could beat obesity, too.

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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.