John Marcille

John Marcille

Employers stand by the exit signs in the back as echoes ring through the great hall of public discourse about the Patient Protection and Affordable Care Act. Everybody wants to know: What will be the effects of implementation? Meanwhile, the businesses that sponsor most of the coverage in the country jiggle their keys and check their watches. They’ve got a pretty good idea.

As our cover story points out, reform makes it inviting for companies to get out of the health insurance game for good. Thomas Reinke, the author, shows that as the costs of reform for health plans mount, the establishment of exchanges will make it much easier — and inviting — for employers to head for the hills.

As we were putting this issue to bed, a survey was saying that 91 percent of doctors “reported believing that physicians order more tests and procedures than needed to protect themselves from malpractice suits.” According to the survey, in the Archives of Internal Medicine, an overwhelming number of generalists (91 percent), specialists (89 percent), and surgeons (93 percent) hold that view. Tests and procedures are ordered whether they’re needed or not. As much as $60 billion might be lost due to defensive medicine, the study says.

Paul Fronstin, PhD, a senior researcher and director of the health research and education program at the Employee Benefit Research Institute, says that these days the employer asks the health plan: What innovative ways can you come up with to keep my costs under control?

Insurers address this in many ways. Yet, as the study about defensive medicine indicates, they do not now, nor ever will, control every aspect of medical coverage. That’s another thing employers know.

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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.