John A. Marcille

John A. Marcille

Whether you take the story of the fall literally or consider it an interesting contribution to humankind's reservoir of mythology, the lesson of the narrative cannot be easily dismissed. It is about how free will entered the world riding on a serpent's tail. Remember that once the decision was made, the apple eaten, and Paradise left behind, the blame game got under way. And you are wondering what this has to do with health care coverage, aren't you?

Contributing Editor MargaretAnn Cross's cover story examines discretionary spending in health care. She finds that nobody really knows for sure just what procedures patients will decide to do without once faced with the reality that the cost comes out of their health savings accounts. "Discretionary" is a vague concept right now.

Given that serious illness will eat at the 80/20 coverage that kicks in after it swallows an HSA whole, you wonder why there isn't more concern about this. At the very least, clear definitions need to be in place, especially since the spending a patient may avoid, at his or her discretion, involves preventive care. ("Guess I'll skip a mammogram this year and buy some cool eyeglass frames.") The bill for that choice eventually comes due.

MargaretAnn's article discusses some plan designs that draw a line between discretionary and necessary by reducing or eliminating copayments for drugs, for example, whose use is in everyone's interest. But how is a person to be sure that he has indigestion and not a heart attack?

Like Adam and Eve, some will always gamble that they won't get caught. I am reminded of those enticements that Atlantic City casinos used to offer old folks: Free transport and $10 to gamble. The smart ones would pocket the cash and stroll the boardwalk.

Managed Care’s Top Ten Articles of 2016

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.