John A. Marcille

John A. Marcille

Some things presidential candidates promise are later forgotten. Blame our curiosity, then, for suggesting that one idea floated during the campaign merits examination: George W. Bush's assertion that he would reform Medicare in the image of the Federal Employees Health Benefits Program.

John F. Kennedy remarked that one of the most surprising things he discovered as president was how little control over events he possessed. Bush, unfortunately, may be in for a similar awakening.

As senior editor Frank Diamond's cover story points out, many people have held the FEHB program up as an example without realizing how difficult it would be to replicate. Talk, in other words, is cheap.

While the article doesn't specifically address Medicare and the FEHB program, experts almost unanimously opined that the system could possibly be expanded — but only by baby steps. Ed Flynn, the associate director for retirement and insurance for the Office of Personnel Management, which runs the system, labels more grandiose notions as "simplistic."

Even expanding the FEHB program into the private sector would be difficult, because such a move would represent an administrative burden for smaller companies. (Bigger companies try to offer as much choice as the FEHB program, but how many companies have nearly 9 million employees?)

Still, there is no denying that the FEHB program has trans-ideological appeal — Democrats, as well as Republicans, have sung its praises. Why not? It applies government oversight — as opposed to interference — to a system in which 245 health plans must compete like crazy for business.

As one expert put it, there are "hundreds of nuances where the FEHB program is better than Medicare, because plans that don't have nuances don't keep customers."

In that sense, candidate Bush was on to something. Let's see what President Bush can do with it.

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.