Open wide. When one is reaching for a metaphor to describe the Affordable Care Act’s effect on health care, that’s a good start, lending itself to an image of a python about to swallow something bigger than its esophagus, or a dentist with instruments of torture.

Insurers should be very concerned, as our cover story by Michael D. Dalzell on page 22 points out. It looks at five ACA trouble spots, but note the sidebar that cites five more that are not quite so dire, but still irksome. Lack of space made us focus on the main problems, and leave many others for later discussion. How many? Hard to say when you’re talking about a monster law that is 907 pages long, with regulations that go on for 70,000 more.

Health care lawyer Kathrin Kudner, displaying a talent for understatement, points out that “it’s not organized in a user-friendly way.”

The ACA reaches into all our lives, and inevitably it reaches into a few corners of this issue. For instance, accountable care organizations (ACOs) are a bulwark of health reform, and insurers need to be careful here, as well. Our story on page 48 explains the four basic elements every ACO contract should contain.

Meanwhile, the U.S. Preventive Services Task Force calls for nearly universal screening for HIV (page 38). It’s a grade A recommendation, meaning that plans must cover the service and patients need not pay anything out of pocket — another ACA provision.

Lest I be accused of being a noodge or even someone with a political ax to grind, let me quickly point out that everybody — and I mean everybody — agreed that something needed to be done to fix the system, and the ACA was a true compromise plan. In the end, the ACA might very well succeed, but not without some discomfort.

Do pythons ever gag?

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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.