John Marcille

John Marcille

I have been watching the national health care reform debate with interest and amusement — as we all have, no doubt. Not working for an insurer, a TPA, or a PBM, I can look at the process with a little more detachment than someone worried that his company might be made redundant, as the Brits like to say, by something in a national health care reform bill.

But my interest is turning into irritation. In any public policy debate, it ill serves the nation to endure lies, half-truths, misrepresentation, misinterpretation, and disingenuousness. Arguments should be won or lost on their merits. So when Senate Minority Leader Mitch McConnell trotted out the objection to a government-sponsored health plan as “making people stand in line and denying treatment like they do in other countries with national healthcare,” it got my back up. Just as when Sen. Lindsay Graham, also a Republican, said that in national health systems, “The first thing that happens — you have to wait for your care....”

Now turn to page 6, where Contributing Editor John Carroll, in discussing a California law requiring timely appointments with physicians, presents stats that show that we don’t do well on that score at all. Our rate of same-day appointments for chronic illness complaints was about the same as Canada’s and far worse than other countries.

Then we have the backers of the so-called public option. No, they say, this is not a stealth plan to move the country to a national health system. It’s just that a lot of folks can’t get insurance under the existing system.

Gimme a break. Of course it’s a tryout for a national system. The real question is whether the nation wants that system, or whether such a system can preserve large parts of the existing market system. But we are not ready for that discussion. As economics professor Tom Getzen tells us on page 43, reform as currently discussed in Washington is not going to do the trick. So we’ll be having this discussion again in a few years, no matter what Congress does this year. I hope that will be an honest discussion.

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.