John A. Marcille

John A. Marcille

We hope that the big "2009" on our cover caused you to pause. To be sure, it's an odd benchmark, even if it is a half-decade away. Goalposts placed five years apart hold a certain credence for those of us who spent our childhoods doing school drills in which we hid under desks. The "other side" lived and, unfortunately for its peasants, died by five-year plans. (We found out only later, though many suspected at the time, just how painful social change could be when engineered by those who tote guns.)

Even in our society, however, eras often overlap neatly placed decade markers. The calendar indicates that the 1960s lasted from 1960 until 1969 (or 1961–70, if we think back to the Y2K discussions). Many say the '60s action, uneven as it was, occurred between November 1963 and April 1975. A long decade. The 1990s, too, were nonstandard, lasting from November 1992 until September 2001. Sure these are arbitrary markers, depending on how you regard events as varied as John F. Kennedy's assassination, the fall of Saigon, Bill Clinton's election, and the 9/11 terrorist attacks.

Still, the mere passage of time, as many woebegone realized on Jan. 2, is not, in and of itself, such a big deal. (Certainly not worth that extra toast, was it?) Events happen whenever.

Who's to say that, when all is recorded, 2009 will not be the watershed mark for health care and that neat, marketable 2010 is just the first of the many years that followed?

In our cover story we ask prominent and thoughtful experts to ruminate about what we'll find in 2009. It's an impressive lineup: Helen Darling, Leonard Schaeffer, Kenneth S. Abramowitz, Joseph Newhouse, Alice Gosfield, Paul Fronstin, Newt Gingrich, and J.D. Kleinke. They say some interesting things — some of which challenge conventional wisdom circa 2004. (Abramowitz, for instance, doesn't think consumer-directed health care, will fly.)

For those of us with really long memories and an organizational bent that borders on the scary, it might be worth saving their predictions for when that magic year does arrive. Who was right? Who was wrong? We'll probably be too busy trying to predict what will happen in 2014 to notice.

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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.