John Marcille

John Marcille

As with all major social legislation, it will take years for the significance — and the inevitable unintended consequences — of the Patient Protection and Affordable Care Act (PPAC) to become clear.

But first, an anecdote. We now have this individual mandate. Five years ago, contributing editor Martin Sipkoff and I did a long interview with Newt Gingrich that became part of a cover story on his interesting ideas about health care reform. Many whom I know to be politically conservative applauded the article. Yet here’s the thing: If there was one message that stood out for me, it was Gingrich’s insistence that we need the individual mandate. Now, guess what political group is aiming at the mandate as a way to bring down the reform law? It doesn’t take much to amuse me.

Millions of new enrollees? What a windfall for insurers. But for the managed care industry — and this was to be expected — there’s also stuff not to like in the law. America’s Health Insurance Plans is not alone in observing that PPAC (let’s see if this is the abbreviation that catches on) doesn’t do much to hold down utilization and provider fees. At least, that is how I interpret AHIP’s brief statement that “ultimately, the success of health care reform will depend on whether or not soaring costs are brought under control and coverage becomes more affordable for working families and small businesses.”

We will be covering many of these provisions in individual articles over the next few months, or as long as it takes. This month, it’s the attack on Medicare Advantage. By rights, MA should be a growth area because these plans offer a lot of extras to beneficiaries. But on the other hand, they do cost Medicare around 13 percent more per capita, compared with traditional Medicare, so it was a tempting target. Contributing editor John Carroll tells us in the article that starts on page 14 that some MA plans will do just fine.  

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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.