John A. Marcille

John A. Marcille

Making subtle distinctions is a talent not usually associated with mobs. That doesn't mean that the "people," so celebrated by poets and demagogues, aren't often right. In this country, we like to think that they're more often right than not. Carl Sandburg said in his poem, I Am the People, the Mob: "Do you know that all the great work of the world is done through me?"

Passage of the Patients' Bill of Rights, which may be imminent, may not go down as one of the great works of the world, but rather as the fruit of mob judgment: "HMOs — bad." There was also some demagoguery: "Nothing persuades an HMO to do the right thing like the fear of liability," said Sen. Edward M. Kennedy.

Funny how he neglected to mention that the health system had hemorrhaged under fee-for-service medicine, that most people are satisfied with their benefits most of the time, and that many of the larger HMOs are already providing, as the Washington Post notes, "much of the care that a federal law would guarantee."

Kennedy certainly didn't mention the fact that we are faced with a national paradox: medical costs that won't stop rising, and HMOs reluctant to say "no."

Have plans brought much of this upon themselves? Absolutely. Some have made some penny-pinching and callous decisions that have allowed enemies to portray them as penny-pinching and callous. The system's dismal PR record is right down there with the oil industry and the FBI crime lab.

However, it should be noted that Sandburg's poem was published in 1916. In the following 10 years, he would turn an historian's gaze upon one of our nation's most fascinating leaders and produce a monumental biography of Abraham Lincoln.

Biographers, of course, don't have to agree with everything their subjects thought or said. (They don't have to like their subjects much, though there isn't much doubt that Sandburg greatly admired Lincoln.) It would be interesting to find out what the poet thought of Lincoln's line: "There is no grievance that is a fit object of redress by mob law."

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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.