John Marcille

John Marcille

Fallout from the Medicare Modernization Act promises to rain down for years to come. Among many other things, the MMA created the Citizens' Health Care Working Group to encourage Americans "to engage in an informed national public debate to make choices about the services they want covered, what health care coverage they want, and how they are willing to pay for coverage," according to Section 1014 of the act.

To get feedback, the organization launched a road show that P.T. Barnum might have been envious of. "We have held six hearings with experts, stakeholders, scholars, public officials, and advocates," the group says in the preamble to interim recommendations that it released June 1. "We have conducted 31 community meetings, as well as special topic meetings and sponsored events, in more than 50 communities across the nation.... Citizen responses to the Working Group's Internet polls (over 10,000 as of May 15) were studied. Finally, we have read close to 5,000 individuals' commentaries on health care matters submitted by residents of this country."

What's this? The very first of six recommendations says, "It should be public policy that all Americans have affordable health care." Number two? "Define a 'core' benefit package for all Americans."

Health insurers have a huge stake in this discussion. The group wants to appoint a committee to help define what would be covered under such a package. Members will include "patients, providers, and payers. . . ."

It will be interesting to see how this plays out. Meanwhile, Uncle Sam wants to hear from you. Go to www.citizenshealthcare.gov to read the recommendations and to comment on them. Comments will be taken until Aug. 31. And look for our cover story in August on the pros and cons of a standard or "core" benefit package.

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.