November 20, 2018
Walgreens, Humana in talks to combine 
The Wall Street Journal is reporting that Walgreens Boots Alliance and Humana are in early talks to take equity stakes in each other. As the newspaper notes, the deal makes sense as a defensive move against the CVS-Aetna merger and with Amazon beginning to make some waves in the pharmacy business (see the item below). 

Get big or go home seems to be the way it goes in American health care these days. 

The Journal was careful to describe the talks as "preliminary discussions." The two companies already have some dealings. In August, they announced that Humana would be opening up senior-focused primary care clinics in Walgreens stores. 

Bruce Japsen at Forbes reported earlier today that CVS expects to close the Aetna deal shortly after the holiday on Thursday. A couple of state insurance departments have yet to sign off on that deal.
Mercy Hospital shooting highlights hospital danger and NRA vs. docs on gun violence
The shooting at the Mercy Hospital in Chicago yesterday is yet another horrifying instance of gun violence-and a reminder about the vulnerability of hospitals and the people who work there. 

"Hospitals are the only place that is open twenty-four hours a day, seven days a week for anyone who needs care," Gail Blanchard-Saiger, vice president of labor and employment with the California Hospital Association, said in a HealthLeaders article three years ago, a statement that now seems disturbingly prescient.  Two years ago, Elisabeth Rosenthal, who is now editor in chief of Kaiser Health News, wrote an article about hospital security for the New York Times. "...more and more American hospitals are arming guards with guns and Tasers, setting off a fierce debate among health care officials about whether such steps--along with greater reliance on law enforcement or military veterans--improve safety or endanger patients," wrote Rosenthal. Here at Managed Care, one of frequent contributors, Susan Ladika, took a look at the problem of violence against nurses in our May 2018 issue. As Susan reported, 20% of registered nurses and nursing students report that they have been physically assaulted.

The Mercy shooting also fueled more antagonism between the NRA and doctors who support tighter gun laws. The American College of Physicians published a position paper about reducing gun violence a couple of weeks ago after the shooting at the Tree of Life synagogue in Pittsburgh. The ACP said the medical profession has a "special responsibility" to talk about the prevention of gun violence and that physicians should counsel patients about the risk of guns. In response, the NRA tweeted that "someone should tell self-important anti-gun doctors to stay in their lane." 

Yesterday and today, doctors and others launched a flurry of #ThisIsMyLane tweets. One example: Mahua Dey, an Indianapolis neurosurgeon, posted a picture of a blood-stained bullet and tweeted, " Bullet I took out of a 6 month old's brain. @NRA you created my lane!"
Amazon health care initiative hires BCBS of Mass exec
CNBC reported  yesterday that the still-unnamed Amazon-Berkshire Hathway-JP Morgan health initiative has hired Dana Gelb Safran, the chief performance and improvement officer at Blue Cross Blue Shield of Massachusetts. Her Amazon title, says CNBC, will be simpler: head of measurement. Slowly but surely, the health initiative's CEO, Atul Gawande, is putting together his team. In September (again CNBC broke the story) Jack Stoddard, the general manager for digital health at Comcast, was named the thingamajig's  chief operations officer. 

Safran's bio describe her as one of the "lead developers" of BCBSMA's Alternative Quality Contracts, which the Massachusetts insurer's version of ACOs. Safran was coauthor of a 2012 Health Affairs article about the contracts that concludes that global budgets and pay-for-performance measures and incentives "can begin to slow the underlying growth in medical spending while improving the quality of care." Early in 2017, with some of the same coauthors, Safran reported results of a different study in Health Affairs  that compared higher socioeconomic status patients in the Alternative Quality Contract practices with lower socioeconomic patients in those practices. The findings showed that quality of care gains (by some measures, anyway) were greater for the lower socioeconomic patients than those with a higher socioeconomic status. One hopeful inference is that value-based payment models might work to narrow health care disparities.
Amazon getting busy in the medication business
Speaking of Amazon, Healthcare Dive is reporting today that a research note from Jeffries says that Amazon's OTC drug business, called Basic Care, is booming, and that the online retailer is getting ready for a big push of PillPack, the online business it acquired this summer. PillPack specializes in packaging medications for people with multiple prescriptions. 

Is Larry Merlo worried, too busy with the Aetna, or wondering what will happen if and when Walgreens and Humana tie the knot? 
Some 2020 homework
So with the midterms now in the rearview mirror, the folks at Health Affairs are getting us ready for 2020. 

If you've got health care wonkery tendencies, both are well worth your time, maybe after you are done digesting turkey on Thursday. Alas, they are behind the journal's paywall, so here's a taste:

Glied and Lambrew note that the various flavors of public options and/or Medicare expansion may be politically attractive but "technically and operationally difficult." Medicare for All, the full-fledged version, would reduce the role of profits in health care and reduce administrative expenses (an applause line for Democrats). But Glied and Lambrew say "the line item for this single new health program would constitute at last half of all federal expenditures." That might give many Americans pause. 

Senior Contributing Editor Timothy Kelley took a look at Medicare for All and Medicare expansion in our October issue and made the point that Medicare for All might be just too much change. 

Chen goes over the state innovation approach that was given its fullest legislative expression in the Graham-Cassidy-Heller-Johnson legislation considered by the Senate in 2017. The goal of turning health reform care over to the states and paying for it with block grants is to lower costs, expand coverage options, and give state leaders flexibility to make choices that will work at state  level, Chen writes. He also sees the federalist approach to health care reform as a way to bridge (you might say fuzz over) some strong disagreements among conservatives about health care reform and coverage. 

And what about pre-existing conditions? In Chen's view, the laboratories of democracy will need to steer clear of tinkering with the ACA's prohibitions on exclusions because of their abiding political popularity. 
Peter Wehrwein
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