John A. Marcille

John A. Marcille

Gail R. Wilensky tried to warn us. Wilensky, who ran Medicare for Bush père in the early 1990s and is now the John M. Olin Senior Fellow at Project HOPE's Center for Health Affairs, was the subject of our Question & Answer department back in July. In that interview, she doubted that Congress would pass Medicare reform, which would include a prescription benefit, before the Fourth of July recess, as many insiders were then predicting would happen.

She did, however, add that "there may be some possibility for compromise that's not obvious at this point." As we were putting that issue to bed, that "possibility for compromise" suddenly appeared when Sen. Edward M. Kennedy, Massachusetts Democrat, endorsed one of the versions of the bill. Should we stop the presses? Should we pull the interview? Wilensky remained adamant that nothing would pass, and we added an "editor's note" at the end of her interview to give us some wiggle room.

Finally, after what? — is it more accurate to say six months or 38 years? — Medicare has a prescription drug benefit. And health plans will play a prominent role in what could arguably be the most significant social policy development since welfare reform or the passage of the Americans with Disabilities law.

A whole lot of money, $400 billion, is going to be thrown at health plans, doctors, drug companies, and hospitals to make the system work. Starting in 2006, some of the ways Medicare beneficiaries will be able to get a prescription drug benefit will be by joining PPOs, HMOs, or some other type of private health plan that also provides the rest of their care.

"It is the beginning ... of privatizing Medicare, make no mistake about it," Kennedy thundered during the debate.

It is also the beginning of a unique opportunity for health plans. The managed care industry, the New Republic noted several years ago, "has compiled the most spectacular record of negative public relations since the nuclear power industry of the 1970s."

Medicare reform is another way of digging out from under the PR muck. Make it work, make it better than it was before and even the industry's harshest critics will have to admit that managed care does good while it does well. Failure is not an option.

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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.