John A. Marcille

John A. Marcille

There is every reason to think that the growing development of genetic tests and therapies will have a remarkable effect on health care. Who can help but feel a thrill at such possibilities as restoring the body's ability to create insulin, or preventing Alzheimer's disease, or identifying people who are most susceptible to various types of cancer — and then correcting that susceptibility?

Wonderful stuff, no doubt about it.

But this biotechnology revolution — I don't think that term is an overstatement — will produce some collateral damage, as the military might put it. In this month's cover story Managing Editor Mike Dalzell has put together a thoughtful and provocative report on the knotty problems that biotech advances are posing to physicians and health plan administrators. Take privacy of medical records, an issue that is buzzing around Washington in other contexts. Did you know that genetic assays sometimes may not be, technically, part of the medical record and not privileged? What if a medical group or an HMO declined to hire you because it knew that you had a greater-than-average chance of getting breast or colon cancer?

The great promise genomics brings to health care provides grist for the health policy mill, when you consider what demand for genetic services is likely to be. There aren't enough trained medical professionals who know this field. Genetic therapies will be expensive. Some hard decisions lay ahead.

Another provocative article on benefit design (which, as with everything we publish, is presented for the sake of discussion, not advocacy), can be found in this issue. Cyril F. Chang, Ph.D., of the University of Memphis, discusses health plan and employer attitudes toward smoking cessation programs, and proposes ways to consider — societally and at the employer and plan level — how such programs should be funded. And if that's not enough provocation for you, see our assessment of the present state of the hospitalist movement.

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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.