Category: Future of Health Insurance

Payers In The Future…

Screen Shot 2017-03-10 at 8.19.39 AM Check out this story. What you will find are the results of a PWC survey of more than 100 health insurance executives. The topic? What will the payers of the future need to look like. The big piece here is that in the future, insurance companies will need to work with providers rather than abusing them. Collaboration in such areas as data sharing, for example, might help to break down the silos that currently exist and the current tendency for payers to abuse, rather than please, practitioners. Bottom Line. I’m guessing that these executives have this spot on. How many stories have you heard about the aggravation that practitioners must go through in dealing with payers, and the negative impact all of this has on patient care.  Amazing that this shameful state of affairs has been allowed to exist this long. Unlikely that this nonsense will continue much further into the future!

Performance Based Rebates For Diabetes Drugs

screen-shot-2017-01-03-at-12-30-02-pm Entering into the realm of performance-based deal making, Merck has signed a contract with Aetna to base the rebates for Januvia on clinical outcomes. Read about it here. Payers clearly like this kind of deal, and pharmaceutical companies are willing to enter into them in order to increase access and sustain sales of products that otherwise have plateaued. Bottom Line. Let me get this straight. Doctors are compensated based on performance. Drug companies are compensated based on performance. What confuses me here is how do you tease out the interaction of physician performance and drug performance? And where does patient adherence fit into all of this? Not simple!

PWC Strikes Again

screen-shot-2016-12-15-at-2-03-08-pm Yes folks. It is time to once again return to the well and get more free stuff on the WEB from PWC. Check out their latest report, and find out what they see as the most important healthcare issues in 2017 and how we should be responding to them. Like. The little snippet pictured above, that reminds us that no matter what happens to ACA under President Trump, any future insurance plans need to keep in mind that in terms of what is most important to people, it’s the premium stupid! Bottom Line. Drill down to the additional documents that PWC offers here. Go ahead and register with them. Then sit back and review the hundreds of thousands of dollars worth of information and insights that PWC has thoughtfully provided, once again, at the amazing price of $0.

Is Aetna Going To Become Aepple???

aetnaApple According to this recent report, Aetna is going to start to subsidize the purchase of Apple Watches by their members.  Why? From Aetna’s side, the theory is that the watch’s standard health apps, supplemented by some custom apps they are developing, will keep their members healthier and thus provide a positive return on investment. Apple’s motivation is clear. The Apple Watch has not exactly been jumping off the shelf, and thus this is good way to move 50,000 out of the warehouse to Aetna employees, who will get them for free, and potentially millions more if this program gets rolled out to members. Bottom Line. One of the great disappointments of the Apple Watch has been its failure to revolutionize the world of health and wellness “wearables.” Will this alliance move the meter on this parameter? I am guessing not, but I would like to be wrong.

Systematic Incompetence

Health Care Blog Check out this blog post. Immerse yourself in the cases reported there. Ponder how preapproval, billing codes, etc. are simultaneously making the costs of medical care higher and the quality of care delivered lower. Quite a combination, especially since the original intent of  third party payers was to do the reverse. While Frank Lloyd Wright spoke eloquently about form following function, this is a clear case of function following form. Bottom Line. My key takeaway here is in the first couple lines of the post. I’d never really thought about this before, but I am struck by the profundity of the thought that while competence is by definition homogeneous, incompetence displays itself in many different forms. Some of these forms are random and idiosyncratic, others are more dangerous because they are actually engineered into systems. Like third party payment rules!!!

Trump On Healthcare

Donald Trump healthcare Inquiring minds want to know. What would “The Donald” do with healthcare in the United States? Unlike with the last blog, where I asked for 20 minutes of your time, today I’m only suggesting that you spend a minute and change to watch this NYT video that attempts to answer this question, and spend a little extra time reading the accompanying article. Bottom Line. Okay you caught me. I lied. Both the video and the article open more questions than they answer. Do you leave this experience more confused than edified? Me too! I think that is sort of the point!


Fire I’ve demonstrated this to you before, and I’m going to do it again. More specifically, one more time, I’ll call on zdoggmd to demonstrate that a good musical parody is better than a lengthy article in making a point. Bottom Line. In this case, the point being made is that increasingly, physicians are under amazing amounts of pressure to get patients “treated and streeted.” BUT. They are under even more pressure to avoid readmissions, even of the most compromised of patients. And yes, it’s all about money. Double Bind? Paradoxical? Hypocritical? You bet!!!

More Semantics

Suneel Dhand In my previous blog, I talked about the importance of semantics in determining the balance between physician clinical judgment and patient inputs. Here’s another physician commenting on the importance of words. “Doctor,” he elaborates at some length in this post, is a term with denotations and connotations that are important in the delivery of medical care. Likewise “Physician.” Much is lost, he argues, when doctors allow themselves to be referred to as “providers,” “prescribers,” etc. Bottom Line. Quite simply, Dr. Dhand believes that physicians should push back on semantic abuse. How? By informing those developing computer systems, telephone menus and other media that they will no longer stand for being peripheralized in the name of equality and political correctness. I think he makes a good point!

I’ve Got To Admit It…

ebn When I think about “employer wellness programs,” I usually picture a gym filled with office workers in company tee shirts on treadmills. BUT. A recent article reveals several new trends in this area. Even the terminology is changing. Employee “well-being” is the new mantra. The “variety” of plans offered, it is reported, was found in recent survey research to be especially valued by employees. Freezing of eggs “for nonmedical reasons” and other non-traditional offerings are greatly broadening the spectrum. Getting employees to “engage” with such programs in greater numbers is increasingly a priority. Bottom Line. Boundaries are going to blur here. Helping employees prepare financially for retirement is now being subsumed under the rubric of “well-being” programs. Watch for an ever-broadening array of offerings in this zone that are designed to enhance employee recruitment, satisfaction and retention.

The Art of The Deal

Express Scripts Yup, that’s the title of an old Donald Trump book.  It could also serve as the rallying cry for Express Scripts’ latest efforts at cost containment. The hell with trying to negotiate lower prices across manufacturers! Instead, pick one product for the treatment of a disease like Hepatitis C, strike an exclusive deal with one manufacturer (in this case AbbVie) to provide their drug at extremely favorable pricing, and tell other manufacturers (e.g., Gilead) to go pound sand. No deal, no reimbursement. None! Read this Reuters article and learn about the impact that such an approach might have upon drug manufacturers’ profit levels. Bottom Line. Increasingly, the stakes involved in reimbursement, especially for specialty drugs, are too high for traditional forms of negotiation to be efficient. But what impact will a covered/not-covered approach have on medical practice and patient treatment choices?