Working quickly, President Bush has drafted the first half of his prescription drug plan for Medicare and sent it to Congress. But the so-called "immediate helping hand," a short-term block grant program to subsidize prescriptions for low-income beneficiaries while Congress works out a permanent benefit, has few supporters in Congress. Both parties want to decide the bigger issue now.

The Democrats' position is familiar: a universal prescription drug benefit tacked onto the existing Medicare program. Bush has put a stake in the ground, favoring a drug benefit only as part of larger Medicare reforms similar to those recommended last year by a blue-ribbon panel headed by Louisiana Democratic Sen. John Breaux and Tennessee Republican Sen. Bill Frist.

The Republican chairman of the Senate Finance Committee, Charles Grassley of Iowa, says he will not entertain the reform package, and instead plans to work with Democrats to pass a drug benefit of some sort by summer and make incremental reforms to Medicare. Washington insiders say the GOP does not have the votes to pass a large-scale reform bill, and both parties are more eager to cut a deal and pass compromise legislation to establish a drug benefit, rather than become mired again in gridlock.

Still, reform advocates are going to try. A bill introduced Feb. 16 by Breaux and Frist is modeled on the panel's recommendations. Under it, a new Medicare board would establish a competitive system to pay Medicare+Choice plans and beckon them back to the program. Incidentally, making participation in Medicare more attractive to plans had been Congress's intent last year when it agreed to restore $12 billion, over five years, in funding that had been stripped from them by the Balanced Budget Act.

But from Congress's point of view, Medicare HMOs — which had been trimming supplementary benefits as expenses mounted — were supposed to use the cash to add benefits. Instead, health plans are using the extra funds to boost payment rates to physicians and hospitals, who long considered them inadequate, and thus expand their provider networks. Expect both parties to bring this up as reform talks get under way.

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.