John A. Marcille

John A. Marcille

Strolling the linguistic battleground upon which we toil each day, one nearly trips over the clichés "if it ain't broke, don't fix it" and "leave well enough alone." "They'll do," you think, as you pick them up, brush them off, and march them once again into the breach.

But cliches are like stereotypes — sometimes they're dead wrong — and these two certainly don't apply to our cover story, which presents the case that insurers and employers should spend more money on healthy people. In other words, that they shouldn't leave well enough alone and that "it" — in this case the healthy segment of the population — should be fixed even if it isn't broke.

At the risk of eliciting yet one more groan, perhaps it is time to start throwing good money after good. The government is starting to come around to that idea. ("Come around to that idea." Another cliché? That's the problem with this tack — it's far too easy to find yourself unconsciously committing the sin that you're self-consciously pointing to. Sort of like the person who brags about how humble he is.)

As this issue was going to press, federal officials announced that beginning next year, Medicare will pay for an initial comprehensive physical exam for new beneficiaries. This will be just one of a number of preventive services that will be covered under changes brought about by Medicare reform.

"Medicare had it backwards, spending 99 percent of its resources treating seniors after they got sick and only 1 percent on preventing illness and promoting wellness," says Health and Human Services Secretary Tommy Thompson.

Consider that a ... um ... word to the wise.

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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.