When Congress returns this month, the topic of patient rights will be simmering on the front burner. Before adjourning for its summer recess, the House passed the GOP-backed Patient Protection Act on virtually a straight party-line vote, 216–210. President Clinton vowed to veto the Republican measure in its current form. Unable to reach agreement on how many amendments both sides could offer, the Senate delayed consideration of the bill until Congress comes back.

The American College of Emergency Physicians came out against the bill because its guidelines for emergency care coverage — the prudent layperson standard — was "too restrictive." The American Association of Health Plans, which opposes government mandates of any size, shape or color, does not like any of the versions of patient rights legislation floating around Washington.

The key difference between the Senate GOP bill and the Democrats' proposal is health plan liability. The Democrats — with the vocal support of President Clinton — say patients unequivocally should have the right to sue plans. Republicans, on the other hand, would allow patients to appeal denials of coverage to a panel of experts, but not permit them to take HMOs to court.

So what do Beltway insiders think will happen when Congress returns? It's anyone's guess. Consider these comments from Chip Kahn, chief operating officer and president-designate for the Health Insurance Association of America — and oft-described ultimate Washington health care insider: "I can see legislation passing the House and Senate, with Speaker Newt Gingrich and Senate Majority Leader Trent Lott — along with President Clinton — agreeing on a compromise bill, as happened with welfare, immigration and the Balanced Budget Act. I also can see a bill sputtering to a halt in a quagmire in the Senate, like what happened with tobacco."

And, Kahn said, in his opinion, both scenarios are equally likely. The outcome is not much different from what many pundits foresaw at the beginning of the year: a battle royal until Congress adjourns for Election Day.

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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.