An insurance framework proposed by the Commonwealth Fund includes a national insurance exchange that would offer both private insurance plans and a new public plan option “that would achieve near-universal coverage.”

The report estimates that premiums for the public plan option would be at least 20 percent below those currently available for a comparable package of benefits in the private market.

The public plan option would prompt private plans to innovate and reexamine the way they operate.

As described in “The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way,” the system would change the way care is paid for by increasing the value of primary care. It would move from a fee-for-service design to more bundled methods of paying that encourage coordinated care. It would also hold providers accountable for improving health outcomes.

Individual and small businesses would benefit because the new option would provide a less expensive alternative for the uninsured and underinsured than what is now available. Savings would derive from lower administrative costs and use of Medicare’s reformed provider payment rates.

Cathy Schoen, senior vice president at the Commonwealth Fund, says private insurers would want to participate in the exchange because they “would have access to the entire under-65 market. If you didn’t participate in the exchange, employers and individuals would have a hard time finding you. If an insurer did not participate, it would lose access to business. The public plan is a major new competitor, and a private insurer would want to be seen side by side with it.”

The report estimates that implementing this type of insurance exchange could result in a cumulative reduction in national health expenditures through 2020 of $3 trillion.

But Schoen cautions that “the insurance reforms alone won’t be enough. If you don’t have the payment and the information system reforms, we won’t see that $3 trillion savings.”

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.