John Marcille

John Marcille

In the movie Jerry Maguire, Dorothy Boyd (Renée Zellweger) throws in her lot with the title character, played by Tom Cruise. She quits her job to join him, but then remembers one important detail. Will she have health benefits?

Our cover story relates how employer-sponsored coverage, while not going the way of Tyrannosaurus Rex, is suffering worrisome erosion. Just look at the graph on the cover.

Watch now, because I'm about to step out on thin ice. There are possibly college courses in which the study of Jerry Maguire plays an important role. (Where were these courses when I was in school?) Recent graduates will tell me if my interpretation misses the mark. Still, I venture to say that the fact that Dorothy asks about benefits after she quits her job signals her romantic feelings for Jerry, feelings given voice during the course of a film that gave us the line: "You had me at 'hello.'"

If he hadn't had her at "hello," you can bet that she would have asked about health benefits before she decided to join his nascent company.

Only romantic love can make health benefits an afterthought. The real, in-the-trenches love — for a spouse and/or children — makes people think long and hard before deciding not to elect coverage. Still, more people are in fact deciding not to take benefits while, at the same time, more companies are deciding to offer fewer benefits, or none at all, and consequently, enrollment in health plans isn't what it could be.

"Because of the cost, because of the cost, and because of the cost," Paul Fronstin, the director of health research for the Employee Benefit Research Institute, stressed to contributing editor John Carroll, who wrote the article.

Definitely not the stuff of romantic comedy.

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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.