John Marcille

John Marcille

Princeton University economist Uwe Reinhardt, PhD, says that American businesses have the habit of reinventing old institutions and giving them new names. “The famed Massachusetts Connector was once known as Health Insurance Purchasing Cooperatives (HPICs), then Health Alliances by the Clintons, then something else again by Republicans, and so on. Always the same,” says Reinhardt.

Concerning the accountable care organization, the subject of our cover story, Reinhardt says that it is a good idea, though not really a new one. “It may be claimed that these differ from Kaiser because they can go across institutions. But that is not new either. In the 1990s we called such organizations virtual HMOs.”

The problem, as Reinhardt sees it, is that the public has little staying power for any of these efforts. “The minute it involves reducing someone’s revenues below expectations, providers will trigger a backlash and tell their patients quality will suffer and then you get a populist backlash,” says Reinhardt. “The argument is that this is not about cost containment. But it is! The Clintons, too, argued that the managed care-managed competition framework they advocated would do both — constrain the growth in health spending and enhance quality — by forcing HMOs and the providers behind them to compete on both cost and premiums. I still have the slides from those years.”

Health care has always been a political issue. It is even more so in this season when the word reform trips so readily off everybody’s lips. Of course, now the talk is about health insurance reform. Concessions are going to have to be made by some or all of health care’s players at some point. Demographics demand as much. Though, as Reinhardt says, that might not settle things.

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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.