Timothy Kelley

Twenty years ago, as a weekly-newspaper reporter in the town of Enumclaw, Wash., I spent a day covering flooding that had afflicted several nearby towns. Then I came home to my basement apartment and discovered that the "news" had touched me more intimately than I'd known. I was flooded out.

I thought of that day after what happened recently when our company chose a new health plan. Knowing a thing or two about the process because of our line of work, our group publisher made sure that if he selected any plan with a closed panel, that panel would include all of the primary care doctors with whom we staffers had existing relationships. He found a well-regarded HMO that met that test. So far, so good.

It took less than a month for verbal fisticuffs to break out in my mailbox between my doctor and my new HMO. "We very much regret Dr. X's decision to enter into a restrictive agreement with a competitor which, in part, requires him to reject all Plan Y members," huffed a letter from the HMO, while the physician's memo insisted that "no action that we have taken would have any impact on our ability to provide care to you . . . The decision to terminate the relationship was made by Plan Y. I fought this decision for the good of my patients to no avail."

I don't know who's right. But when my doctor adds that he has "good relations with other insurers," it's like telling a flood victim that it's dry in the Arizona desert. Our small company can afford only one health insurance option, and the exhaustive paper work has been done. Despite some concerns left over from a surgical procedure last year that make me especially prize continuity of care, and despite the best efforts of my employer, it looks like I'm now doomed to go doctor-shopping.

As an editor I understand that this is part of a market transition that also promises new ways to improve the quality of care.

But as a patient I resent it.

As the saying goes, there's got to be a better way.

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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.