John Marcille

John Marcille

Health care spending averaged $7,026 per person in 2006, according to our cover story by contributing editor John Carroll. By 2017, that number will shoot up to $13,101, accounting for 20 percent of GDP (this year, it’s estimated at 16.3 percent of GDP).

Over the years, many approaches have been used to try to control spending, many of them becoming the subjects of stories for this publication. Without much trying, I can think of a dozen: disease management, pay for performance, formulary tiers, consumer-directed health care, managed Medicare, provider- quality ratings, wellness, cooperation among players, tax reform, employee education, wellness promotion, benefit-based copayments.

And capitation.

Still, the costs keep rising, thanks mostly to our inventiveness. A study by the Congressional Budget Office titled “Technological Change and the Growth of Health Care Spending” says that advances in technology account for about half of health care spending in the last several decades. Nobody wants to give up the technology, though.

Marylou Buyse, MD, director of the Massachusetts Association of Health Plans who is quoted in our update on RomneyCare on page 46, will often ask audiences: “If you could take health care insurance premium rates back to where they were in 2000, would you?” Unanimously: Yes.

Would you go back to those rates even if it meant losing the technology gained since 2000? Unanimously: No. In fact, it’s a unanimous “no” even when the go-back-to year is 2005.

“I don’t think that there’s an appetite in the public to give up what it considers to be even marginal, incremental gains in technology,” says Buyse.

I don’t recall if we’ve ever done a cover story on rationing, but maybe it’s worth considering.

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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.