John A. Marcille

John A. Marcille

Perhaps it's just coincidence. The National Committee for Quality Assurance issues its State of Health Care Quality report the same month that a study is published in the Journal of the American Medical Association that dismisses the idea of grading health plans. Talk about irony.

As noted in our News and Commentary department, the NCQA's release of this information has almost become a rite of autumn. There's a videoconference, scads of news releases, and generally just a whole lot of to-ing and fro-ing. At this publication we certainly take notice and report NCQA's doings, but we're also aware that the organization has detractors.

"An HMO that says 'I don't want my stuff reported' doesn't report it," Uwe Reinhardt, PhD, professor of health economics at Princeton, once pointed out to us. "Imagine General Motors saying to the Financial Accounting Standards Board, 'Actually this year was not so good so we've decided not to have a financial report.' That's roughly what the HMO industry has said, which is of course quite ridiculous."

Reinhardt's correct on both counts: It is ridiculous, and that is what HMOs have been saying, according to the JAMA study. Half of all HMOs participating in HEDIS stopped reporting their performance data in 1998 and 1999. Of those that dropped out, the HMOs that scored low the previous year were three times more likely to do so than were those who had had higher scores. JAMA's conclusion? "Voluntary reporting of quality data by HMOs is ineffective; selective nondisclosure undermines both informed consumer decision making and pubic accountability."

Pretty damning, even when taking into account that one of the authors is David Himmelstein, MD, a longtime critic of managed care. Critics have their purpose: Recent headlines indicate that those who had said that some capitalists are too greedy may have had a point.

It should also be remembered that Reinhardt, when he made that comment, was discussing the feasibility of creating a Health Care Fed, a government regulatory body that could compel reluctant plans to issue standardized quality reports. It's not too late.

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.