John A. Marcille

John A. Marcille

Is "crisis" too strong a word for the increasing concern by businesses over the current inflation in health care costs? I wonder. Contributing editor John Carroll, in his cover story on this topic, cites the continuing cries of pain from the business community.

The pain is real. Even though the dollar has declined relative to the Euro and other currencies, domestic producers are saddled with health care costs that are nearly half-again as high as other industrialized countries (our competitors), despite, as we reported in April, clear evidence that ours is far from the world's healthiest population.

Naturally, there's talk of a government take-over, and I'll bet that there are quite a few executives who would find that more palatable than excutives found the stillborn Clinton plan of a decade ago — a plan that was mischaracterized as socialized medicine, but was actually heavily managed competition.

Let's face it: Nearly everyone who reads this publication is benefitting from health care inflation. Plan or provider, more income is welcome. Cost control is being driven by employers (under the guise of being driven by consumers), and plans are starting to respond with new programs, but there's doubt that "consumer-driven" health care can apply more than a temporary brake, and concern that it may actually harm some people's health.

Some health plans see this situation as a golden opportunity. It is an opportunity, but is our inertia so pervasive that we cannot respond with the kind of controls that will bring health care inflation into balance with the rest of the economy? Will workers stand for rationing (let's call a spade a spade)? Will employers resist unhappy workers' demands? Can insurers come up with anything truly new, effective, and acceptable? Please don't force me to guess at the answers.

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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.