John A. Marcille

John A. Marcille

It is unusual, although not unprecedented, for Managed Care to devote a cover story to a political figure. A fair amount of what comes from politicians is nothing more than hot air, as we all know. Certainly nothing that would even survive "peer review lite."

Newt Gingrich, however, is a force to reckon with.

Let me say up front that we are not endorsing his point of view. Nor are we rejecting it. We are reporting it, because even though he has been out of Congress for a decade, this former speaker of the house remains highly influential. A few weeks ago, the New York Times ran a prominently placed profile of him titled "Health Care's Unlikely Surgeon."

He will be a keynote speaker at the annual National Managed Health Care Congress in Washington, D.C. in early March. And there have been recent rumblings about Gingrich for president in 2008.

Contributing Editor Martin Sipkoff and I talked with Gingrich in late February in his Washington office.Martin's article has plenty of food for thought.

Newt Gingrich is probably further to the right than many of our readers (many others will agree with many if not all of his statements), but I believe that most can agree with his observations on the paternalism of the existing system, the unaligned incentives of third-party payment.

Frankly, one of the most appealing aspects of the Gingrich vision, from one societal point of view, is his insistence that everyone "participate in the insurance system," as he says in his most recent book. Poor people would get tax credits and/or Medicaid vouchers. Everyone else would have to buy insurance. If employer plans survive, OK. If not, buy it yourself. Economists tell us that when our employer buys insurance for us, he is using money that would go into our paycheck anyway, so what's the big deal?

Well, the big deal may be economies of scale. Believe me, it costs more for me to insure my auto directly with the insurer than it would cost my employer to insure the same car as part of a fleet. Bulk purchasing. If you want to control health care costs, yet get the third party out of the picture, you need to preserve this aspect of the system.

Gingrich does envision large risk pools being established for poor people, but even so, I see costs exploding if we go to a predominantly individual market, with the result that people become underinsured.

We must be clear that Gingrich goes very far in his thinking. He requires consumers to become very engaged in their health — exercise, eat properly, take proper preventive measures — things that I have not seen uppermost in the so-called "consumer-driven" plans of today. Clearly, it would be great for individuals to behave more responsibly, and yet, no matter what the economic system, many of them will not.

Tough, says Gingrich. Part of me applauds that, and part of me is appalled.

What we do need is creative thinking. It used to be that great men were credited for the major changes in history. Nowadays, we see social currents and even environmental change as major factors. But in the short run, our ideas are all we can work with.

And how can you ignore a man who says "First you save lives, then you save money"?

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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.