Real World Evidence
Frank Diamond
But most insurers are taking a wait-and-see attitude even though in some clinical areas, such as diabetes, real-world evidence (RWE) has been a true game-changer. Payers have a pessimistic view that RWE can help them. It doesn’t help that respected voices in health care agree.

A U.S. Federal Judge John D. Bates blocked the $37-billion Aetna-Humana merger yesterday, in a decision that says Aetna misled the public on why it was pulling out of ACA insurance exchanges in 15 states.

The ACA requires that insurers cover people with pre-existing conditions. It looks increasingly clear, however, that the Trump administration will dismantle the ACA.

Real World Evidence
Thomas Reinke

Jennifer Graff
Nt’l Pharmaceutical Council

There is momentum building to use observational studies to investigate the safety and efficacy of medications in new ways. Drug companies are using them to establish the value of medicines in negotiating prices, rebates, and formulary placement with payers.

In a move that could destabilize insurance markets, a top advisor to President Trump said that he might do away with Obamacare’s requirement that everyone be insured, Bloomberg reports.

A woman does not have the right to contraceptive care under the ACA; not in so many words, at least. What the law states is that insurers and employers must cover preventive services for women, and that can be open to interpretation, according to STAT.

Editor’s Desk

“Repeal and replace” is looking pretty scary these days for the millions of Americans who have gotten health insurance coverage through the ACA. It’s also proving to be treacherous political terrain for the Republicans in Congress and President-elect Donald Trump. Turning a rabble-rousing threat and political gesture into government policy ain’t no walk in the park.

Viewpoint
Jason Duhon
CMS depends on encounter data submitted by state Medicaid programs to maintain the massive Medicaid Statistical Information System (MSIS), a database of claims, encounter data, and beneficiary eligibility information. Poor encounter data can hinder quality measurement in multiple ways.

Good news for consumers, but a headache for insurers. The Auvi-Q, made by Kaleo, includes a voice mechanism that gives consumers step-by-step instructions on how to inject epinephrine with an automatic retractable needle system, USA Today reports.

How’s this for a simile? “Millions remain uninsured, and most Americans’ coverage comes with gaping holes, like a hospital gown that looks pretty good in front but leaves a lot hanging out in back.” Now there’s a breakfast visual for you.

Measuring Quality
Joseph Burns

Peggy O’Kane

After 25 years, the Healthcare Effectiveness Data and Information Set (HEDIS) is still criticized for focusing on process and taking up doctors’ time. But it has been incorporated into physicians’ workflow and may yet be instrumental in bringing about value-based care.

There’s been much heated debate (but isn’t there always with this topic) about just what affect restrictive state abortion laws and the closing of abortion clinics have had on abortion rates, accordging to a report by the Guttmacher Institute, a research group that supports abortion rights.

Measuring Quality
Thomas Reinke

Avedis Donabedian, MD

The measures most often used today to assess care quality are process measures. Actual outcomes, of course, are harder to measure than whether a certain action has been taken—checking the feet of a patient with diabetes, for example. But many experts don’t think process measures get at the heart of quality.
Measuring Quality
Richard Mark Kirkner
The problem, say hospitals and some analysts, is that rating hospital quality is not so straightforward. How a hospital delivers care is multifactorial and complex, they argue, so trying to cram that into a single score is misleading and can end up like rating a restaurant on its parking.
What To Expect in 2017: Managed Care Year in Preview
Jan Greene

Amazon Echo

Getting older people to bring a new technology into their homes has been more difficult than expected. Nevertheless, the tech industry continues to work on new options, and there are some intriguing possibilities on the horizon for 2017 and beyond.

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.