John Marcille

John Marcille

We tiptoe into the waters when fishing for a metaphor. That’s especially true when the fish sought is called complementary and alternative medicine. Like the barkeep Rick in Casablanca, we will remain “carefully neutral” by not naming specific therapies. We will only say this: Sometimes we want so much for things to be true that we will ignore science, and even common sense, that suggest otherwise.

Which leads us to accountable care organizations, the subject of our cover story. We have followed the life of ACOs from theory to enactment of the Affordable Care Act. All the while, we’ve included voices that said (to make this a true surf-and-turf offering), “Where’s the beef?”

Even if ACOs worked the way proponents want them to, even if providers could get a handle on actuarial risk (with or without the help of plans) or costs, the math just didn’t seem to add up.

There are about 5,800 hospitals, and 780,000 physicians in the United States. As Alice Gosfield, one of our editorial board members, puts it: “They are not all going to be in ACOs.”

That’s not the only thing that doesn’t add up. Providers that so want ACOs to become reality now keep a wary distance after the Centers for Medicare & Medicaid Services announced the regulations that would govern these entities. They don’t see how they can make a profit and improve care by adhering to 65 mandatory quality measures.

What isn’t mandatory is participation in ACOs. All of a sudden, providers are checking their watches and jingling their car keys. They want out of here. The voices that we’ve featured all along, like the ones in this issue’s cover story, aren’t saying “I told you so” in so many words. Still, we have a feeling that ACOs are not ready for prime time.  

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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.