The National Committee for Quality Assurance will soon offer its blessing to disease management programs. NCQA is developing a DM certification program intended to recognize regimens that effectively manage chronic illnesses. The program will go live next year.

Stand-alone DM vendors will be eligible for certification, as will in-house DM programs at health plans. Though NCQA is the second organization to enter the field of DM evaluation, it may be first to the finish line. The Disease Management Association of America, a DM trade group, has been discussing a DM accreditation program since its inception early last year; while no program has evolved, DMAA has issued "standards of care." DM vendors are split over whether accreditation is a necessity, and what it means in expense and administrative burden.

Meanwhile, NCQA is moving forward with two other initiatives. One will encourage makers of HEDIS-related software to vie for its approval. The plan is to certify private vendors' HEDIS-compliance software that correctly handles NCQA-supplied test cases. The certification program is to begin next year.

NCQA's other new venture tries to nudge health plans into doing what they can to make the practice of medicine safer. Beginning next year, NCQA will require plans that seek accreditation to show that they are using care-management expertise to address such issues as adverse drug interactions and coordination of care. Such a system would, in essence, require plans to work more closely with their hospitals and physicians.

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.