John A. Marcille

John A. Marcille

If all politics is local, the Institute of Medicine's recent recommendation that the federal government encourage the states to serve as laboratories for health care is a wise one. There's no reason to think that good ideas can't or won't come from the states; they are ideal testing grounds for new concepts.

The report, "Fostering Rapid Advances in Health Care: Learning from System Demonstrations," covers in detail many of the failings of the present system and describes programs that could or should be undertaken to address many of the issues. I can think of no other undertaking that has tried to categorize our troubles and propose a way out of them, and it seems that a well-crafted effort to have states conduct demonstration projects has some chance of producing useful prototypes for other states and the federal government.

In case you hadn't noticed, this is a program that makes particular sense to the majority of those who are mistrustful of big government and who think the best decisions are made close to home. Having covered local and state governments in a previous career, I am not of that persuasion. Still, the IOM's plan, including chronic care demonstrations in a dozen communities, health insurance coverage experiments in 3 to 5 states, and information and communications technology programs in 8 to 10 states, has appeal.

These programs need to get going as soon as we can make them happen, and they have to be adequately funded — which means the feds. The states, as we are coming to know, are just about bankrupt and cannot run deep deficits the way that the national government has during most of our lives.

We are facing major problems of safety, cost, access and effectivness. I only hope that our health care system doesn't collapse before we get some usable results.

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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.