John A. Marcille

John A. Marcille

The problem of obesity is so vast, broad, and complex that it throws off images that seem at first to be its opposite, something like black holes, stars that absorb light. The intense media coverage over revelations concerning Mary-Kate Olsen's eating problems is an example. Here is a young woman (a very wealthy young woman, a young woman that you'd think hasn't a problem in the world) starving herself to fit in with a distorted view (Society's distorted view? Hollywood's? Are they the same?) of what's beautiful.

Of course, that's an aesthetic issue. This is a journal that focuses on the business of managed care and the clinical issues associated with it. That's just the point. As Contributing Editor John Carroll makes clear in his cover story, it's too easy to throw up your hands when it comes to America's dance with image.

But it's not just about how you look. It's also about how healthy you are. And whether you are a starlet starving yourself or one of the many who are supersizing themselves, you know that America is starting to wake up to the fact that we have a weight problem.

More to the point, employers are beginning to get hip to how much this costs. It's a lot, and increasing. They're turning to health plans and asking: "Just what are we going to do about it?"

This is like your boss asking, "What are we going to do about it?" The "we" is immediately translated to "you." Some health plans have taken the stance that society's problem can only be cured by society. That, after all, is how tobacco addiction is being battled.

But it's not that easy. Most obviously, there's the expensive matter of bariatric surgery and who's going to pay for it. How long do you think you can dodge?

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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.