Competition benefits consumers, the theory goes. Policy makers who seek to alter market forces in health care should keep this corollary of capitalism in mind, says the Center for Studying Health System Change, a Washington-based think tank. Put another way, the group says, if too few consumers have a choice of health plans, then insurers are under little pressure to respond to their members' interests.

Almost two thirds have choice

The group's newest data suggest that 64 percent of households that are offered employer- sponsored insurance have a choice of health plans, and the percentage is increasing. This share is higher than conventional wisdom, which holds that just over half of households have a choice. HSC attributes the difference to the fact that just over half of workers are offered a choice of health plans — but when both spouses are employed, the percentage of families with a choice grows.

Company size matters

Not surprisingly, an employer's size tends to dictate whether an employee has a choice of health coverage. Only 1 of 4 people who work in companies with fewer than 50 employees are offered a choice, while the proportion jumps to more than half in companies with more than 50 workers. To prevent adverse selection, many insurers force smaller companies to contract with them exclusively.

More people, more choices

Families living in populous areas have more choice than those in sparsely populated locales. Just over half of families in rural and small metropolitan areas are offered a choice, while 7 of 10 families in markets of more than 4 million can choose between plans.

Same destination, different roads

For all the talk of an "empowered consumer" these days, 64 percent of consumers with a choice of health plans isn't enough to make health plans responsive to members' concerns, the Center for Studying Health System Change says; it would require government policy interventions to give consumers a greater voice. The Health Insurance Association of America, on the other hand, sees government intervention as a sure-fire way to reduce choice. Reacting to the HSC report, HIAA suggests that government intervention would raise premium costs and force many employers to do business with fewer carriers — or drop coverage altogether.


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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.