John Marcille

John Marcille

It seems to me that the combination of the steep escalation of health care costs and extensive effects — at this point we can only guess at how wrenching they will be — of the Patient Protection and Affordable Care Act and other reform measures are promoting a frenzy of efforts to remake our payment and delivery systems.

To some it might feel like walking in mud, but it’s a frenzy compared with the usual pace of health care change. And one of the leading areas of change is the widespread interest in the patient-centered medical home (PCMH). Contributing Editor John Carroll does a fine job of giving us a look at where this widely heralded movement is today.

Now, I have always been a tad suspicious that the concept of the PCMH was developed more for the benefit of the primary care doctors than for patients or health plans or payers, but at the same time, the concept seems to make sense for patients and plans and the primary care docs, if not for hospitals and specialists. So motives aside, testing this out seems the right thing to do.

Yet, as John implies in his article, the evidence is still not sufficient for widespread adoption. Group Health Cooperative, for example, reports getting a 50 percent return on its investment in the PCMH and a more-than-$10 decrease in PMPM expenditures in the single location where it tested the concept. But Group Health is highly integrated and most health care in the nation is not. Plus there was no randomized control group and the gains, John reports, did not reach statistical significance. Further, Group Health is expanding the program to its other clinics.

Still, I have no doubt that in one way or another, many of the attributes of the PCMH will be found in most medical practices within the next five to ten years.

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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.