John Marcille

John Marcille

Supply meeting demand isn’t always good. We watched for years as young doctors displayed less and less interest in primary care. They’re only human, after all. An income difference between primary care physicians and specialists that can be measured in hundreds of thousands of dollars is difficult to ignore.

That’s why the point made by Barbara Starfield, MD, subject of this month’s Q&A, serves as a warning. “The specialist, oversuspecting the likelihood of a serious illness, will do a very expensive and unnecessary workup. And all the things that are done in an unnecessary and expensive workup have a finite chance of an adverse side effect, including death… If you don’t have something that requires a specialist, it’s dangerous to see one.”

It’s difficult to see how the marketplace can fix this problem, since the marketplace seems to be the cause. Health plans will need to come up with some creative approaches.

That’s what they seem to be doing in response to the economic slowdown that’s afflicting the country and industry, according to our cover story by Contributing Editor Martin Sipkoff. Some companies have decided to focus on underserved populations to help get them through.

“Insurers have the ability to change to meet the needs of the culture, and that is what they’re doing,” says Aetna spokesman Mohit Ghose.

Ghose’s remarks underscore just how proactive insurers need to be these days, a sentiment echoed by Paul Ginsburg, PhD, president of the Center for Studying Health System Change.

“Whether plans can continue to adjust to a changing market remains an open question,” says Ginsburg. “Those who do will survive. Those who fail to adjust fail to survive.”

A pretty stark assessment. Good luck.

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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.