The Commonwealth Fund has advanced a plan that it says would insure 44 million of the estimated 48 million uninsured Americans and would offer new health insurance choices to individuals and small businesses for 30 percent less than what employers pay now. Dubbed the “Building Blocks” plan by the Commonwealth Fund, it would preserve employer-sponsored health insurance, Medicaid, and the State Children’s Health Insurance Program (SCHIP), and would offer a Medicare-like option along with a choice of private health plans through a national “health insurance connector” or a purchasing cooperative that is modelled after the Massachusetts plan. The connector would be open to small businesses, the self-employed, and everyone without large employer insurance or Medicare.

According to the article “Building Blocks for Reform: Achieving Universal Coverage with Private and Public Group Health Insurance” the plan could save $1.6 trillion over 10 years if it is coupled with efforts to reform how the United States pays for health care.

The plan proposes to use a national entity called a connector that could offer individuals and small businesses a choice of private plans or a Medicare Extra plan. Medicare Extra is a proposed new insurance product with benefits similar to those in the Federal Employees Health Benefits plan.

About 60 million people would get their health insurance through the connector, most as a result of small businesses deciding to buy into the connector and its plan choices. About 14 million would be previously uninsured and an additional 1.2 million would be individually insured who switch to the connector.

In addition, the plan would require that all applicants receive health insurance with premiums that are community rated, i.e., the rates are the same for all enrollees in a given plan regardless of age or health status (insurers would decide what premium to charge); tax credits to help make premiums affordable; and expanded Medicaid and state CHIP coverage for low-income adults and children.

The proposal would also require employers to either provide health insurance or pay seven percent of earnings up to $1.25 an hour into a pool to help finance coverage.

“If a typical worker made $40,000 a year, the employer would be contributing $2,800 a year,” says Karen Davis, president of the Commonwealth Fund.

Details of the plan and its framework are published in the May/June issue of Health Affairs.

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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.