Peter Wehrwein


Regardless of what you might think about the ACA, there's no question that it has changed the terms of the never-ending debate about the inadequacy of American health care. Cost, not coverage, is dominating the discussion.

No, the exchanges are not out of the woods. But the combination of Medicaid expansion and the ACA exchanges meant that number of American adults without health insurance dropped pretty dramatically from 16.3% in 2014 to 12.8% in 2015, according to the federal government's National Health Interview Survey.

In a piece for the Wall Street Journal last week, Drew Altman, president and chief executive officer of the Kaiser Family Foundation, noted high deductibles are now the top health-cost issue for consumers. As Altman pointed out, high deductibles are having a profound effect on how Americans view and experience health care. They are seeing dollar signs everywhere, electing to forgo certain treatments (you might call this self-rationing), and accepting of cheaper forms of delivery, like telemedicine.

Medications are a double whammy in this era of expanded coverage but with higher out-of-pocket costs. For many conditions, treatment drugs have become fantastically expensive while plan design shifts costs to the patient through dark-art combinations of the deductible, coinsurance, and the like.

The growing number and size of patient assistance programs has been one response to these developments.

But Robert W. Carlson, M.D., the CEO of the National Comprehensive Cancer Network (NCCN) and a medical oncologist at Fox Chase Cancer Center in Philadelphia, called the programs a "double-edged" sword last week during an Association of Health Care Journalists webinar on the "financial toxicity" of cancer treatments. Joseph Burns, the association's topic leader on insurance issues and a contributing editor to Managed Care, moderated the session.

Carlson said to the journalists watching online that cancer treatment is now the leading cause of personal bankruptcy, noting that the new wave of treatments sweeping through oncology are priced, on average, at $10,000 a month. NCCN has added "affordability" as category to its "evidence blocks" for evaluating a treatment, he explained, along with efficacy, safety, the quality and quantity of evidence for a treatment, and the consistency of the evidence.

Patient assistance programs are, in fact, effective in shielding individuals from the crushing costs of new medications. Carlson told the story of a patient of his with metastatic, hormone receptor–positive breast cancer. Pfizer's new drug, palbociclib (Ibrance) was a treatment option but at roughly $10,000 a month, "affordability was an issue." The patient's insurance company told the patient that her cost would be $500 a month, but that was still too large of an expense. Ultimately, a patient assistance program got the patient's expense down to $10 a month. Carlson noted, though that the expense doesn't go away but is shifted and the drug company "still comes out ahead of the game."

Patient assistance programs are "good for the individual patient but perhaps not so good on a societal basis," he said.

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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.