In mid-July, the National Committee for Quality Assurance unveiled HEDIS 3.0, the third incarnation of a health plan quality rating instrument whose initials stand for Healthplan Employer Data and Information Set. Criticized in the past for falling short of measuring the true quality of medical care, NCQA says it has designed HEDIS 3.0 to assess how health plans actually help patients get better.

HEDIS will continue to look at the percentage of board-certified physicians and will now also note whether physicians completed a residency — an addition endorsed by the American Society of Internal Medicine. No longer will the hospitalization rate for asthmatics be analyzed; rather, the appropriate use of asthma medications will be measured.

HEDIS has about 15 indicators to evaluate all groups, but especially the elderly, mothers and infants. Another 30 are being tested and will be in HEDIS 4.0 — due in 1998 — if NCQA deems them necessary. Among the 30 are: smokers who quit, colorectal cancer screening and prevalence of aspirin treatment after a heart attack.

Alan Nelson, M.D., executive vice president of ASIM, cautions NCQA to ensure that there is strong rationale behind requiring plans to report so much information because administrative burdens will be passed on to consumers in the form of higher premiums. ASIM and the American Academy of Family Physicians are evaluating the latest HEDIS version, and plan to make official statements later.

There was bad news for managed care companies in a recent survey of 1,113 Americans on the credibility of 11 key industries. The managed care industry placed second to last. Its only consolation, a scant one, came in the fact that last place itself belonged to tobacco companies.

The industries mentioned also included public utilities, food, pharmaceuticals, airlines, insurance, oil, computer/software, autos and chemicals.

Computer/software companies were ranked most credible. Pharmaceutical companies were next, despite the controversy that surrounded their prices during the health care reform debate of 1993 — 94. But like all industries cited except computers, drug manufacturers received more negative responses than positive. Twenty-eight percent of the 1,113 respondents gave drug companies a four or five — five being most credible — and 30 percent gave them a one or two.

Only 10 percent rated managed care companies "believable." But tobacco companies fared worst; only 6 percent saw that industry as credible.

The study's sponsor, Porter Novelli, attributes its mostly negative results to America's "age of cynicism."

How would you react if one day you got a letter demanding that all referrals to specialists be limited to one visit? Mid Atlantic Medical Services Inc. (MAMSI) sent such a letter to its doctors in July. Physician groups reacted with fury.

The Rockville, Md.-based company, which operates in six mid-Atlantic states and the District of Columbia, says it will terminate contracts of doctors who do not abide by the policy, which is clearly aimed at reducing costs to the health plan.

Peter Sherer, an oncology specialist, told the Washington Post, "The company is using 'scare tactics' to save money at the expense of patients and physicians." Sherer suggested that primary care physicians will be afraid to refer even when patients have serious conditions that require specialty care.

John Littleton, M.D., immediate past president of the Maryland Academy of Family Physicians, is less disturbed. He says primary care physicians need to be responsible for making appropriate decisions. You only need one specialty referral, Littleton goes on: The specialist advises what the treatment should be and the patient returns to the primary care doctor.

MAMSI spokesman Michael Savage says the company does not intend to retract the policy. MAMSI covers 1.7 million lives and contracts with 18,500 doctors — 14,000 specialists and 4,500 in primary care.

During the American College of Physicians April meeting in San Francisco, 164 internists were questioned about whether managed care formularies have changed their prescribing habits. Participating internists, who on average work with five managed care plans, said that managed care strongly encourages use of generic drugs and formulary drugs, but 82 percent added that non-formulary drugs can be prescribed, usually through a special request or if the patient is willing to pay the difference.

The poll, conducted by Hospital Research Associates of Fairfield, N.J., asked if managed care plans used restrictive formularies. Yes, according to 58 percent of those sampled. Internists report that pharmacists frequently call them to change a medication to one they feel is more cost-effective. In nearly two-thirds of the cases, internists agree to the suggested change. Within the next year, internists expect, they will prescribe more generics and will allow the option of substitution more often when prescribing brands.

Yet another report comparing health plans and doctors will be available from a new not-for-profit organization called the Center for HealthCare Economics. It is being funded through a charitable donation of $100 million from the intended merger between Blue Cross Blue Shield of Delaware and Blue Cross and Blue Shield of New Jersey, which has subsequently announced it will merge with Anthem Blue Cross and Blue Shield of Indiana.

Comparative reports about health insurance companies, plans and doctors in Delaware will be available to consumers and employers. The data may include comparison of benefits, value received for the dollar and amount spent on administration and health care.

The organization will be headed by Robert C. Cole Jr., who is stepping down as president and CEO of Blue Cross Blue Shield of Delaware once the merger is final. Cole suggests that people think of the comparative information in terms of reading Consumer Reports "to help you determine which automobile to buy."

— Paul Wynn

Quality benchmarks embraced today by the National Committee for Quality Assurance's HEDIS could herald new demands on physicians from managed care plans tomorrow. So doctors will want to note that the newly released HEDIS 3.0 includes criteria in these areas:

  • availability of primary care doctors
  • appointment access
  • telephone access
  • advising smokers to quit
  • physician turnover
  • board certification/residency training
  • recredentialings
  • physicians paid by capitation

The leading association of managed care organizations reports that HMO enrollment for 1995 climbed to an estimated 58.2 million, up 13.9 percent from 1994. The survey also says that 81 percent of physicians working with HMOs are board-certified, compared with 62 percent of physicians throughout the country.

SOURCE: AMERICAN ASSOCIATION OF HEALTH PLANS, WASHINGTON, D.C.

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.