Washington Initiatives

The prognosis for "HealthMarts" is not all that good. The latest attempt by Republicans to come up with an alternative to President Clinton's Patient Bill of Rights (which is itself treading water) is meeting stiff opposition from consumer organizations — and it's still only in the drafting stage.

Think of HealthMarts as supermarkets for health plans. Employers would fund them and send their workers to them to shop for coverage rather than provide it directly, with employees choosing from a smorgasbord of plans and benefits. "It's kind of like a private version of the Federal Employees Health Benefits Program," says a staffer on the House Republican working group.

Some Republicans are gung-ho about HealthMarts because they think businesses will wind up saving money by pooling large groups of consumers and shifting costs to individuals and families who use more health services. But the consumer's lobby — which includes 57 consumer, provider, labor, senior citizen and disability groups -- released a letter urging representatives to oppose the proposal because, they say, it's antiworker.

Speaker Newt Gingrich is the key player in efforts by the House working group, but some Republicans are confused about Gingrich's stance on health care reform. According to one policy wonk on Capitol Hill, "Newt really does not want to change the system all that much and the working group is way too out-front trying to protect patients." Look for legislation that will combine a watered-down HealthMarts plan and patient protections already put forth by Georgia Republican Charles Norwood in his fading Patient Access to Responsible Care Act.

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.