John A. Marcille

John A. Marcille

The Declaration of Independence, that audacious document, contains the remarkable phrase: "All men are created equal." No one believed it for a moment, not even Thomas Jefferson, who quickly, in the next phrase, cites the "Creator" as the basis of this equality. Only in the eyes of God can this be true, for certainly, in the eyes of Charles Darwin and, today, in the eyes of any biologist or physician, it just isn't so.

The story of health care is a chronicle of just how unequally we are created. Genetics can now dig to scary depths to make that point. At the same time, the consumer-directed health care movement pretends that Jefferson was correct all along.

As our cover story points out, Darwin has not been silenced. The survival of the fittest applies to just how much control individuals can exert over their health coverage benefits. The story asks how can you expect the 90 million Americans with limited literacy to navigate the complex shoals of health care. Further, what will that ignorance wind up costing the rest of society in the long run?

Evolution is a blind machine that doesn't pause to ask questions. So, too, is the marketplace. Ready or not, consumer-directed health care is coming. Health plans and all other players in the system must figure out a way to break information choice down to the "See Spot run" level.

Meanwhile, we wonder. Did the dinosaurs of millennia past think, in any sense that a human identifies thought? Not too likely. They just looked stupidly at the sky as the streaking asteroid hurtled toward their home.

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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.