John Marcille

John Marcille

Dizzy yet? As if there aren’t enough think tanks poring over and trying to interpret the Patient Protection and Affordable Care Act, here comes another. As we were putting this issue to bed, the National Institute for Health Care Reform, sponsored by automakers and the United Auto Workers, released a study that posits that the $5 billion in federal funding for the high-risk pools is not nearly enough. The pools are meant to provide coverage for people who normally can’t get coverage because of pre-existing conditions, and are meant to be a bridge to when the insurance exchanges kick in — scheduled for 2014. (For a comprehensive discussion of both the high-risk pools and the coming exchanges, see contributing editor Martin Sipkoff’s article.)

The study states that “using one plausible definition of the eligible population, almost 7 million people are potential participants, or about 5.6 million if those with access to other coverage were excluded. The $5 billion in federal funding is sufficient to provide subsidized coverage to only a fraction of potentially eligible people.”

Perhaps in too short a time another study may state that the $5 billion is far too much, and sound an alarm about overspending. That’s just where we are right now when it comes to health care reform.

There is one thing that we’re fairly confident about, however. In his cover story about how plans and providers must cooperate more effectively, managing editor Frank Diamond cites the PricewaterhouseCoopers study “Prospering in a Post-Reform World.” That study, and Frank’s article, note that the very structure of reform dictates that the old tension between players will soon become less relevant. We’ll go way, way out on a limb in a maelstrom of information and say that’s a reasonable bet.

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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.