September 2016

Both presidential nominees have big plans for changing the health insurance world, but hurdles are many and victory on November 8 is only the beginning. Here’s what may be in store.
Joseph Burns
This year’s two presidential nominees have taken aim at high drug prices — and pharma. A solution may require not just rhetoric but cooperation between industries.
Jan Greene
Divided into many different pressure groups, physicians mostly can live with the ACA. But now they have MACRA, MIPS, APM, and other puzzles to figure out.
Richard Mark Kirkner
Trump’s promise to repeal and replace the ACA could cut into revenues, but so could Clinton’s proposal for a public option. Readmission rates, bundled payments, ACOs — they fly under the radar of presidential politics and may continue regardless of the election results.
Robert Calandra
Clinton has come out against the Cadillac tax, but what will replace the revenue? If the ACA is repealed, House Republicans have proposed capping the tax exemption for health benefits as a way to curb the appetite for expensive health care benefits.
Charlotte Huff
Clinton wants to expand the existing program. Trump’s signals are mixed, but the Republican platform calls for replacing entitlements with premium support to buy private health insurance.
Robert Calandra
MediMedia Research survey of our readers shows that they are evenly split on the nominees, and opinions on the ACA span the favorability spectrum.
The ACA was health care reform that left the health care system largely intact, says Princeton sociologist Paul Starr. A Clinton presidency could mean important adjustments to the law, including addressing the omission of a public option. Trump’s proposals would, in his view, effectively end regulation of insurance, and responsible insurers should be worried about fraudulent forms of insurance entering the market.
Interview by Peter Wehrwein
Medicaid expansion often means a hollow benefit, says Scott Gottlieb, MD, a resident fellow at the American Enterprise Institute and a leading conservative expert on health care policy. And the exchanges are in trouble with little political support. But Gottlieb says there will be some reluctance for sweeping reform because of a “fatigue factor,” so targeting the exchanges may be the best way forward for Republicans.
Interview by Peter Wehrwein



Departments
9 million Americans buy health insurance outside the ACA exchanges. They make too much money to be eligible for subsidies and can often get coverage with a broader network of providers.
Susan Ladika
Tomorrow’s Medicine
HeartFlow says its algorithm can reduce the need for invasive angiograms by crunching data collected by noninvasive CT angiograms.
Thomas Morrow, MD
Value-Based Care
The law was supposed to give drugmakers freedom to share health care economic information about their products. Efforts to get clarity from the FDA are stepping up.
Michael D. Dalzell

Managed Care’s Top Ten Articles of 2016

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.