Most Newsworthy New Year’s Birth: ACA is an Infant With Boundless Potential

Paul E. Terry, PhD

Today’s news, of course, featured the birth of the first baby of the New Year: Amber Chrisha L. Caponpon in Guam . Cheers to the proud parents and here’s to the hope that all the extra hoopla doesn’t add to mom’s sleepless nights. Just as Amber’s arrival (at 12:04:30 a.m.) will forever be a major milestone for the Caponpon family, January 1, 2014 also marks the most monumental day in the history of American health policy. The individual insurance mandate, the sunsetting of underwriting as we know it, and the planned obsolescence of the term “pre-existing conditions” in insurance all presage a fundamentally different era for access to health care. Of the 5.7% of those in the individual market, .6% will not be eligible for financial help if they want to continue buying in the individual market. In exchange, starting today, up to 47 million nonelderly uninsured will be eligible for new and/or more affordable health insurance. The good news is that there is no turning back from this miracle arrival. The bad news is there is no starting over either. The stork delivered it with warts and all.

Watch for symptoms of post-policy depression

As much as producing progeny is exhilarating, parenthood also comes replete with mood swings, irritability, and trouble sleeping. Untold new demands will last for months and, given that withdrawal from family and friends is common for new parents, the stresses of parenting may go unnoticed by those who truly care. Similarly, the basic hygiene needs of the ACA will likely dominate policy debates in the year ahead. Given the taxing gestation period and the painful web portal complications, it will be perfectly understandable if those closest to this birth are too overwhelmed to think of much else than the daily care and feeding of this fussy bundle of potential. I, for one, am watching attentively for just such signs of post partum malaise in the health policy community. It will show up as an inordinate political focus on farming and immigration policy in spite of the fact that the ACA falls far short of solving the nation’s most intractable economic burden: the unhealthy habits and declining health of Americans. I’d propose that the treatment is relatively straightforward: It’s time to open the health reform 2.0 savings account and commence with enthusiastic planning about this new infant’s future — and to get busy creating a new sibling.

It’s time to put health into health care policy

Most American’s probably think Obamacare is an insurance portal that’s still on life support. In fact, the ACA arrived today with a lot of wellness in its personality. That the word wellness shows up 86 times in the bill means that disease prevention is part of this baby’s DNA. Starting today, for example, watch how one molecule (section 4205) affects nutrition labeling at chain food retailers. Playing to basic behavioral economics principle, the ACA asks for “prominent, clear and conspicuous” information about the availability of nutrition information, including the calorie counts on foods by serving size. For proponents of making healthy choices easier choices in an otherwise obeseogenic culture, it’s a lovely dimple of an idea. But it’s not even close to solving the problem of unfettered promotion of, and youth access to, bad-for-you foods.

A more substantial ACA trait can be found in section 2705 which allows employers to build financial incentives into their employee wellness programs. I’ve discussed the opportunities that come with this innovation in a prior blog post that includes additional references to the threats to wellness program success if the rules are misconstrued as an opening for a new form of underwriting. As much as wellness professionals are enthusiastic about the prevention traits of the ACA, this progeny has an ego largely vested in access to care. It was the obvious chromosome to root for.

Now, if we stand any chance of containing health care costs in America, health reform 2.0 must be about substantial investments in disease prevention and chronic disease management. Foremost, the next reforms must be about what should become the dominant gene in health care policy: health.

So next time, when people ask me what policy trait I’m hoping for, I’ll say with conviction, You know, just as long as it’s healthy, I’ll be happy.

Paul E. Terry, PhD. is EVP and chief science officer at StayWell Health Management.

Managed Care’s Top Ten Articles of 2016

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.