Frank Diamond

Whenever someone at a party talks about a desire to be born in another age, I’ll ask: “But what about antibiotics?” (OK. I don’t actually voice this because I want to be invited back. I do think it, though.)

The first recipient of penicillin was a British constable, Albert Alexander, who, in 1941, had been infected by a rose’s thorn. He deteriorated rapidly before being treated with the cutting edge medication. He made a dramatic comeback, but then relapsed and died because the medical team had run out of the drug.

Penicillin didn’t become widely available until after World War II. Over the years came the other antibiotics. I am still here thanks to these medications, and there’s a good chance that’s the case with you.

Unfortunately, though, society now faces a variation of what Constable Alexander faced. We’ve reported on, and clinician executives at insurance plans and doctors have been dealing with, the growing problem of antibiotic-resistant bacteria for a long time.

We’re losing — losing so badly that contributing editor Joseph Burns can begin his excellent article about the problem with this dramatic statement: “We have entered the post-antibiotics era.”

Constable Alexander didn’t have enough. We don’t have enough of antibiotics that work as intended. Antibiotic resistance is the world’s most pressing health care threat, according to the Centers for Disease Control and Prevention.

Here’s the brutal bottom line for health insurers: They aren’t doing enough, according to the National Committee for Quality Assurance. Plans’ efforts to ensure proper use of antibiotics have been stagnant, even in decline, over the last five years.

That needs to improve. This is not the sort of situation one can, as Constable Alexander might have put it, muddle through.

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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.