John Marcille

Uwe Reinhardt, PhD, in our Q&A, says — somewhat tongue in cheek — “… that is another miracle of American health care: We don’t know prices. We know Medicare prices — at least you could know them — because they are in the public domain. But prices negotiated between hospitals and doctors are trade secrets. So if you don’t know prices, competition can’t work.”

There has always been a need for price transparency, and now might be our best opportunity yet to achieve it. Our cover story on page 16 by contributing editor Joseph Burns warns that even with the help of the Affordable Care Act, transparency won’t come easily. In fact, some of the ACA’s efforts in this area are making some consumers more confused.

And it’s easy to get confused, as even savvy customers note. A Viewpoint by John Sung Kim, who runs a health technology company, includes this interesting tidbit regarding a recent hospital stay.

“While the hospital charged $49,675, my insurer paid only $34,772. The rest was ‘forgiven’ by the hospital.” That was for one night, with no surgery. “Just a CT scan, eight shots of Dilaudid, cable TV (no HBO), bed, and a bland continental breakfast.” Sobering, but health plans still see an opportunity. Rick Weisblatt, PhD, a vice president at Harvard Pilgrim Health Care, says in our cover story, “If we can drive more volume to lower-cost providers, then, in theory, we should be able to save on health insurance premiums. If the market becomes more competitive and providers are forced to be more efficient and then improve their cost structure and lower their prices, that should mean we could lower the cost of insurance.”

What was that word Reinhardt used? Miracle? Almost everything we’ve achieved thus far was once considered a miracle, so we might be on the right course.

Managed Care’s Top Ten Articles of 2016

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.