John Marcille

John Marcille

Long ago we all learned about common flaws in logic, including the one that goes: I performed a rain dance on Tuesday. It rained on Wednesday. Ergo the dancing caused the rain. Last month, we published an article about how the presidential campaign may affect managed care under the scary title “Plans Unsettled by Prospect of Democrat in White House.” The sub-headline took the edge off by adding that “the health insurance industry might be able to help itself by coming up with ideas to influence the presidential debate.”

So, using another bit of faulty logic, I’ll emphatically deny that Aetna President Mark Bertolini read the last line of that article and then hurried on down to Charlotte, N.C., where he called for major health care reform that would cover everybody in the United States.

He wants this done via a public-private effort and not by a single-payer system. “The result of a single-payer system is decreased access and services,” Bertolini says in a Q&A with the Charlotte Observer.

In that conversation, Bertolini brandishes a phrase that’s gaining currency, the “young immortals,” people who don’t accept that they’ll ever get sick, let alone die.

When you subtract the YIs, illegal immigrants, and those on public assistance rolls, he estimates that about 15 million to 17 million are left who really can’t afford insurance.

He also notes that the greatest hindrances to insurance are coverage mandates; that employers have to be, and therefore will remain, involved; and that people are terrified of losing their insurance.

Finally, who of the presidential candidates does he think offers a plan that will prove most effective? Sen. Hillary Clinton, that’s who.

Will wonders never cease?

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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.