Doctors returning home from World War II knew that critically ill or injured patients had a better chance of survival if they were treated in a hospital. In 1976, emergency medicine became the country's 23rd recognized medical specialty. A lot happened between points A and B.
Recent mergers didn't quiet the growing frustration and concern employers, pharmacists, consumer advocates, state legislators, and some members of Congress have with the PBMs' lack of transparency. There are still so many questions, and getting answers anytime soon will be a chore.
The PBM industry is under fire these days for what critics call its lack of transparency and its knotty contract language, secretive pricing schemes, and an inscrutable assortment of rebates, discounts, side deals, and administrative fees. Some see partnerships with insurers and retailers as a possible solution. Opponents see a risk of even higher drug prices.
Bundled payments work for hip and knee replacements for several reasons. The surgeries themselves are now fairly routine. For most patients, the recovery is usually predictable. There are also some golden opportunities for reducing expenditures that don't compromise care.
Getting vertical theoretically will allow the new entities to capitalize on efficiencies in care management, total cost of claims, and other programs while creating an all-in-one health care product that provides more services at less cost. At least that's the spin.
The ACA-and more specifically, the individual ACA exchange market-is doing quite well these days, thank you very much. ACA premium prices have stabilized and even gone down for many plans. In October, CMS announced that the average premium for the second-lowest-cost silver plans for 2019 had decreased by 1.5%.
CMS is granting waivers that impose work and other new requirements on some Medicaid beneficiaries. Medicaid managed care plans are wary of the added administrative complexity-and possibly a change in the Medicaid population's risk profile.
After premiums for 2017 increased, on average, by 32.5% over premiums for coverage in 2016, rate filings by insurers for 2018 show rates going up by only 8.8% over 2017 rates. But it could take at least five years for the ACA exchanges to shake all the bugs out.
PBMs say their deals need to be kept private so they can drive a hard bargain with manufacturers. But employers, consumer groups, and legislators are calling for more PBM transparency. There's bipartisan support for legislation that would force more openness.
The ACO, a creature of the ACA that often gets confused with its progenitor, seems like it will survive-and maybe even thrive-in whatever healthscape emerges from the Republican anti-ACA push. But just what will happen to the various forms of the ACO that are now in place?
New York State's Target Case Management (TCM) program was created in 1990 by to help people with mental health and substance abuse issues stay engaged in their care. It's been very successful for people with HIV as well. Can it be expanded for other chronic conditions?
Investors are plowing millions into telehealth startups. Millennials could be eager adopters. But these at early times and it may take years--and some regulatory changes--for profits to materialize.
The author's nephew suffers from a rare form of familial hemophagocytic lymphohistiocytosis. His organs shut down and he's placed in a medically induced coma. Meanwhile, costs mount to $4.9 million, most of it paid by an employer-sponsored health plan.
A year ago you probably couldn't find a Las Vegas bookmaker willing to give odds that the ACA would still be the law of the land in 2018. Turns out that repealing Obamacare and crafting a replacement acceptable to various factions of the GOP is not so easy.
PBM consultant Linda Cahn says that if Amazon gets into the PBM business it could insist that drugmakers simultaneously submit the net discount price for each of their drugs for the subsequent six months. Amazon could then publicize every drug's actual price, by drug and by therapeutic category.
A few days after his victory, President-elect Trump told the Wall Street Journal and later CBS's 60 Minutes that he will consider leaving parts of the law in place, including allowing individuals under 26 to stay on their parents' insurance and not letting insurers deny coverage to people with pre-existing conditions.
As their clout has grown, so has the scrutiny on them. For instance, the Department of Justice and U.S. attorneys for the Southern District of New York and Massachusetts are beginning to investigate the industry's pricing structures, client payment plans, and patient assistance programs.
Trump's promise to repeal and replace the ACA could cut into revenues, but so could Clinton's proposal for a public option. Readmission rates, bundled payments, ACOs--they fly under the radar of presidential politics and may continue regardless of the election results.
