John Marcille

John Marcille

Change is difficult for many people. They fear it, and sometimes with good reason. The changes we observe in the organization of the physician workforce — changes that our cover story, starting on Page 14, is about — are certainly disconcerting to some physicians.

Simply put, the long erosion of small practice is picking up steam, and changes in payment methodology being eyed by Medicare and by private payers will surely encourage small practices to sell out to hospitals or to merge among themselves.

While physicians and hospitals are supposed to be joining and pushing ahead together, it’s hard to ignore the tension that these new relationships can engender. As is well known, doctors — especially older ones — fear loss of autonomy, and they fear loss of income. The autonomy question is difficult; readers who work in health plans know why the emphasis on evidence-based medicine, protocols, step therapy, and the like is necessary, and actually in patients’ interest.

But working in larger groups will bring benefits: less need to worry about administrative details, a more regular workweek for many, and a way to keep up with technological changes that Medicare and others are insisting on.

These are among the many upsides for health plans: Doctors spending more time at doctoring, paying more attention to the whole patient, as more plans and practices figure out the patient-centered medical home and — who knows? — set up the vaunted accountable care organizations.

Just about all of this should be viewed positively by the health plans’ clinical executives. And whether plans actually take a big contractual hit when there are fewer, but much larger practices — that remains to be seen. At the moment, I’m looking at the upside.

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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.