John A. Marcille

John A. Marcille

Although we all know that change is inevitable and, in health care delivery and financing, highly desired by many stakeholders, most of us prefer evolution to revolution. Revolutions have a habit of being uncontrollable, and most of us want to stay in control as much as we can.

Health care cost inflation is the big issue today, but it shouldn't overshadow quality improvement. Both cost-control and quality improvement have been basics of managed care since the concept took root after President Nixon signed the Health Maintenance Organization (HMO) Act of 1973. If you turn to the last page of the magazine you will see a report on a federal study that sees inflation moderating somewhat. But somewhat may not be good enough for many companies and consumers who have been hit hard with premium and copayment hikes.

As un-American as many people think a single-payer scheme might be, we are starting to hear more about this "solution" to our problem, and I expect interest to grow. But the status quo is powerful; very few who run any sort of profit-making (or fee-collecting) organization in health care will be eager for a single-payer plan.

At the moment, we find that some stakeholders, as reported in Martin Sipkoff's cover story, are combining — aligning incentives was the term not so many years ago — to nudge physicians, hospitals, and other providers toward exploitation of the best-practices models and the outcomes and other data that are being collected and disseminated. At the moment, this seems like an "us vs. them" situation, but it is amazing how we grow to accept what we cannot change. In this case, we're seeing hospitals respond to Leapfrog Group pressure for drug prescribing and delivery safeguards, and doctors agreeing to systems that reward them for meeting certain statistical goals (e.g. retinal exams for diabetes patients).

Read too the provocative interview with Paul Ellwood, MD, now known as the "father of managed care." Not too happy with how managed care has evolved, he and his Jackson Hole group are encouraging some governmental initiatives to restore functionality to the whole system. Dr. Ellwood, too, is not eager for revolution.

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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.