Frank Diamond

Managing Editor

Many economists wonder if health insurance exchanges will actually perform one of their primary functions when they open in October — increasing the competition among health insurers offering products to millions of new beneficiaries. This according to Stateline, a wire service for the Pew Charitable Trusts (

States in which multiple insurers already compete are likely to see a continuation. States where one plan dominates — and Stateline lists 10 of them — won’t see any difference, according to economists. Of course, there’s always the possibility that insurers, attracted by a burgeoning market, will take the leap, but “Insurance companies have been mostly silent about their plans, with some citing uncertainty about federal and state rules as a reason for holding back,” according to Stateline.

Insurance companies might not be the only ones not to show for the party. The educated consumer, that much-talked-about but seldom-sighted person of interest, might also hold out. The Kaiser Family Foundation finds that a majority of Americans don’t know what exchanges are ( 

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The study was done in March, so hope, if you wish, that a lot of education has gone on in the intervening months. But education is one thing; learning’s another. The Affordable Care Act did foresee the possibility that the uninsured might need some help getting coverage for the first time. So the ACA includes “navigators,” who will help people choose the coverage they need. But will there be enough of them?

California, for instance, wants 21,000 navigators. All of this adds to the costs which adds to the headaches which adds up, some would say, to a fine mess. And the starting pistol has not even been fired. 

Frank Diamond is managing editor of Managed Care.

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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.