John A. Marcille

John A. Marcille

Karl Marx, someone not often quoted in this magazine, once outlined how communism should work: "From each according to his abilities, to each according to his needs." This from a man not known for his succinctness. Perhaps we should give him the benefit of the doubt because, after all, he had no way of knowing just how much misery would be visited upon the world by people bending his words to their own nefarious ends.

Could a benign variation of this method of operation be coming to health coverage? Some companies in the Philadelphia area have begun to link how much an employee contributes to the benefits package to how much an employee takes home. In other words, those who make more pay more.

"Should a worker making $30,000 a year contribute the same amount toward health insurance as a manager making $300,000?" asks the Philadelphia Inquirer. "While the premium for both is the same — nearly $12,000 for family coverage — a $3,000 contribution has a significantly different impact on them. To address that problem, some companies are choosing to tie worker contributions toward premiums to how much they earn."

Judy Lynch, vice president for U.S. benefits at GlaxoSmithKline, one company that is using a salary-based contribution method, tells the newspaper that "We have five different bands, and employee contributions range from a low of $22 a month to a high of $202.... The overall employee contribution is still around 10 percent of our costs. We just distribute it differently." Experts say that such schemes are complex and often difficult to administer. Still, we may soon see other imaginative tinkering with the employer-based system.

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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.