John A. Marcille

John A. Marcille

I think it started a couple of years ago when I'd heard for the hundredth time that the U.S. has the best health care in the world, just after reading about a study showing that we lagged some other developed nations in some significant area. I put the idea on my tickler list, and finally assigned the story to Martin Sipkoff, a frequent contributor to Managed Care.

And it is a powerful story. Martin assembled the numbers, and if you ever had any doubt, you will no longer doubt that we have problems. In infant mortality, life expectancy, even patient satisfaction — we are not No. 1. In fact, we are No. 1 on few if any scales. Does this mean that we don't have some great thoracic surgeons here, some fabulous cancer clinics? Sure we do. It isn't a question of what we can do, it's what we do. Technology and training are not the issue.

Head on over to Google and do a search for "best health care in the world" and you'll get thousands of hits, most talking about America. At best this is wishful or hopeful thinking. Not one person interviewed for this story, including several HMO medical directors, said we are the best. They mostly have profound concerns about our system.

Personally, I think that if we hadn't moved to managed care 10 to 15 years ago, we'd rank lower today. The story doesn't dwell on it, but the solution is political and social will. Medical technology and training are not the problem. I see laudable movement toward improvement of error-prevention systems, but questionable progress toward universal insurance, which, most of our experts indicate, is needed. That would still leave questions about coordination of care, but it would be something.

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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.