John Marcille

John Marcille

Magazines sometimes use what we call breakouts or pull quotes — one or two sentences in large type — to give a page more visual interest and to highlight important points in the article. If we had decided to use breakouts in our cover story on the patient-centered medical home, I would have chosen some words from page 23 and some from page 29.

Let’s remember that the medical home promises to improve care and control costs by giving primary care physicians more responsibility to coordinate care, including preventive care.

On page 23, Jim Bridges, MD, an executive medical director at Blue Cross & Blue Shield of Michigan, gives us some words of warning that, as we look at plans for a massive national reform, are worth keeping in mind: “I wouldn’t think of the medical home primarily as a cost-saving measure, because it’s really principally about quality, and in the short term sometimes quality can cost more.” So here I’ve been thinking that the medical home is a no-brainer, and I find that there might be good reason for some people to be cautious.

And then there is this perceptive comment from MediMedia’s Sue Willette, senior VP and growth officer, on page 29: “You might end up seeing some of what we know today as disease management delivered in a similar fashion, but with the primary care physician at the center, directing all the activity.” I am reminded of last month’s cover story about how PBMs are also expanding into the area that until now has been the domain of DM companies.

So it surprises me a little that what I thought was a benign evolutionary step in care coordination and cost control could have some disruptive elements. And I haven’t even mentioned specialists’ incomes!

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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.