Timothy Kelley

Timothy Kelley

This month, those quadrennial effusions of hokum and hoopla, the national party political conventions, are upon us again. Nowadays their proceedings are carefully staged for TV, and same-party politicians who castigated each other in February will exchange the equivalent of on-camera valentines. Still, the remarks from the rostrum bear listening to — when the ratings-hungry networks deign to cut to the rostrum at all.

We may not hear much from San Diego or Chicago about the 40 million Americans who remain without health insurance. The ambitious universal coverage plan drawn up by President Clinton, his wife Hillary and an intimate, closed-door group of more than 500 health care experts in 1993 to give those uninsured Americans some relief sputtered to an ignominious demise in the halls of Congress. And the Republicans who now preside over those halls may not be any more eager to remind us of this still-unsolved problem than the First Couple are to refresh our memory of how they blew it.

There may be a bit of self-congratulation in both balloon-filled halls, however, for a measure that is apparently headed for a quick Clinton signature as this issue of Managed Care goes to press. That is a law to assure portability of employees' health coverage when they change or lose jobs and to guarantee access to coverage, after a waiting period, for those same workers even if they have pre-existing medical conditions.

The new law is tagged with two names: that of the Democrat who lost to the man who lost to Ronald Reagan in his 1980 landslide election, and that of the daughter of the Republican who lost to Franklin Roosevelt in his even bigger landslide re-election of 1936. But Kennedy-Kassebaum looks like a winner. Arguments will continue over what some say it should have done (parity for mental health?) and what others say it should have done more of (authorizing medical savings accounts?). But in the meantime, this modest measure merits a cheer.

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.