John Marcille

Some physicists, not to mention authors of science fiction, posit that there are an infinite number of universes with infinite numbers of you and me making infinite decisions that are somewhat different from the ones we’ve made that have gotten us to this point in this particular universe. Some versions of me probably write longer sentences. Some versions of you will not continue reading. And some versions of the Affordable Care Act were rolled out smoothly.

That didn’t happen in this universe, however. Studies released last month that look at two bulwarks of the ACA illustrate just how much work needs to be done. The first asks: How effective are patient-centered medical homes (PCMHs)? Answer: Not very.

In a scathing editorial accompanying the study in the February 26 issue of the Journal of the American Medical Association, Thomas L. Schwenk, MD, notes that “there were no reductions in health care utilization of hospital, emergency departments, or ambulatory care services or total costs, and there was improvement in only 1 of 11 quality measures of chronic disease management, nephropathy monitoring in diabetes.” Advocates of PCMH of course have another view — in this same universe.

Then, the Centers for Disease Control and Prevention asks: How well are accountable care organizations (ACOs) performing in the Medicare pilot? Answer: Meh. They show varying degrees of success and failure.

Michael Millenson, a quality control consultant and a member of our Editorial Advisory Board, supports reform. “The PCMH is not important,” says Millenson (http://tinyurl.com/Millenson-PCMH-blog). “ACOs are a lot more important.... The risk was not very great and the reward was not very great. That’s why you have results that are extreme in neither one direction nor the other. ACOs are going to be a change that’s gradual because we don’t want to destabilize the health care system.”

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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.