John Marcille

John Marcille

I don’t know about you, but I’m starting to be overwhelmed by the complexities of the Affordable Care Act, and that’s just the parts of it that interest me. One of those parts is the mandate for health plan purchasing exchanges in the states.

All I can say is that I would not like to be the health plan executive who is responsible for creating the offerings that will to some degree determine that company’s success over the next few years. With millions of new members from the rolls of the uninsured up for grabs, and the possibility that small and large businesses may dump employees into the exchanges, the importance of having attractive products cannot be overstated.

But designing and pricing those plans is going to be a lot different for most companies than designing and pricing the plans that they sold to employers, and the ones they sold on the individual market. I doubt that employees who had employer-sponsored insurance will be eager to do a lot of comparison shopping, and they will be frustrated in evaluating the plans in terms of their individual needs. And the health care companies themselves are looking at a new minefield of risk, where fear of adverse selection may push them to offer plans that offer them some protection, but may not be optimal for members.

These are a few of the problems that Joe Burns explores in his article on private exchanges — laboratories for health plans and employers to try to figure it all out before the exchanges start operating at the beginning of 2014, or so the ACA specifies.

Meanwhile, we have a Supreme Court ruling upholding most of the ACA, yet some states are refusing to participate, opening the door for federally operated exchanges in those states. As much as some governors and legislators might hate the law, do they really want the feds controlling the exchanges? But maybe the insurers in those states might welcome a more consistent regulation.

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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.