John Marcille

John Marcille

We usually leave concern about consumers to consumer publications. At least that's the official position. Many times at story planning meetings, we've killed ideas when we started to say something like, "This is a shame for the poor patients who. . . ." You can fill in the blanks with such phrases as "who can't go out of network to the physician of their choice" or "who can't make sense of the options offered by consumer-directed health care" or "who don't have easy access to their medical records."

They — consumers, patients, employees (much overlap here) — are not our readers and we do not care about them, we joke. Except that we do, and we know that you do too. We care because, first, we are a subset of them and, second, nearly everyone we know falls into that class. Then, on a professional level, we care because what happens to them does affect our readers at health plans and provider organizations. Still, we usually manage to keep sentiment in the background. We're all business.

That's why this month's cover photo is a departure. The woman, a patient, is in not just in physical pain. She's confused by formulary restrictions and, when copayments are high (as they can be for some of the newer pharmaceuticals and biologicals), in financial pain. And this is not counting her physical pain.

Our cover story presents a business problem with a human face. Is your formulary optimal? Or does it have obstructive elements? The human toll is obvious. The business toll is also easy to see.

Now, for solutions. These are harder to come by, but we think the article's author, Contributing Editor John Carroll, reports on some effective approaches that are being tried in various parts of the country. Heaven knows, it's a vexing, complex problem.

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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.