A handful of leading PPOs have agreed to test the National Committee for Quality Assurance's first tool for measuring PPO quality of care. NCQA modified its Consumer Assessment of Health Plans Survey, which it has used as part of HEDIS to report member satisfaction with HMOs. The revisions to the survey will allow PPO enrollees to give feedback about their experiences in such areas as getting needed care, customer service, and claims processing. The survey will become a key piece of NCQA's PPO-accreditation program, which will be released early next year.

In a separate development regarding quality measurement, the American Accreditation HealthCare Commission/ URAC will soon promulgate national accreditation standards for external-review organizations. URAC says final standards are likely to fall along the lines of: scope of reviews; qualifications of reviewers; and components of the process itself, including documentation, time frames, and notification of decisions. The commission is working with a handful of organizations that have agreed to test its standards.

One final tidbit: The Joint Commission on Accreditation of Healthcare Organizations has developed a set of proposed performance measures for hospitals. In another break from its tradition of focusing on hospitals' internal processes, JCAHO plans to measure outcomes for patients with coronary artery disease, heart failure, pneumonia, and pregnancies. The Joint Commission will also provide data about surgical procedures and complications. Results will be compiled into report cards that JCAHO says will allow comparisons of performance across hospitals.

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.