Employers would have to "pay or play" in some proposals for how to boost coverage for the uninsured. The idea can be found in a report, "Cost and Coverage Analysis of Ten Proposals to Expand Health Insurance Coverage," by the Lewin Group, undertaken for the Economic and Social Research Institute. All the proposals would boost federal spending by 1.5 percent to 3.7 percent.

The two pay-or-play proposals examined are by Jacob Hacker, PhD, of the Yale University School of Management and Alan Weil, JD, director of the Assessing the New Federalism project at the Urban Institute.

Hacker's "Medicare Plus" idea would provide employer-sponsored coverage to everyone under a single publicly operated health plan. Benefits would be similar to those currently offered under Medicare.

Weil's "Medical Security System" would be an insurance pool with a selection of private health plans. Included would be at least one zero-premium plan. Those entering more costly plans would have to pay higher premiums. A national board would determine the benefit package.

"Under both proposals, employers must either provide a minimum standard benefits package (that is, the benefits package offered in the public program) or pay a payroll tax," says the report. "Employers who decide to offer coverage would be required to pay a minimum percentage of the premium — 85 percent for workers and 75 percent for dependents under the Weil proposal."

In Hacker's plan, employers would have to pay at least 75 percent for those working 20 or more hours a week and 50 percent for those working fewer than 20 hours a week. So, would these proposals provide universal coverage? Not quite, says the report.

"Under either of these proposals, the number of uninsured would be reduced by about 37 million people, which is equal to about 88 percent of the 41.9 million people who currently lack insurance."

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.