John Marcille

One of our regular departments in decades gone by was called “Employer Update,” and it looked at what was on the mind of health plans’ most important customers: the businesses that buy coverage for employees.

We sort of stumbled into employer-sponsored health insurance, didn’t we? Wage and price controls during World War II forced worker-starved businesses to dangle fringe benefits as a way to compete. After the war, President Truman said, in effect, now let’s do something permanent, which raised such a political stink that all parties backed away with a “This will do, for now.”

That was nearly 70 years ago. Our cover story is a timely “Employer Update” that reports on what may finally be (dipping, once again, into the World War II era for the phrase) “the end of the beginning” of employer-sponsored health care.

Contributing Editor John Carroll points out that the Affordable Care Act flashes like a neon exit sign for businesses wishing to turn their backs on a system that too few find satisfactory. Analysts at Standard & Poor’s pointed out that the ACA means companies can “radically redefine” their place in health care. The temptation to dump workers on state exchanges might be just too great.

Except, as many experts say, this is far from a sure thing. They can’t see how companies can “suddenly tear themselves out of a system that has been woven around the close bond they want to forge with their most highly valued — and paid — staffers.”

Fortune 500 companies are certainly standing pat. Brian Marcotte, MS, CEO of the National Business Group on Health, says that based on recent research, “most large employers are expected to continue coverage for the foreseeable future.”

Check back in 70 years?

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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.