Back in 2005, the National Committee for Quality Assurance called on PPO plans to report HEDIS data, which are clinical measures of quality, with 80 plans — ranging from national carriers to smaller insurers — answering the call. This year, 83 commercial and 58 Medicare PPOs, covering more than 21 million Americans, reported audited HEDIS results. Those findings are in the NCQA's "The State of Health Care Quality 2007."

Margaret O'Kane, president of the NCQA, says she is heartened by the increase in HEDIS reporting by PPO plans. "These plans, which just two years ago reported little to no quality data, are embracing the quality agenda," O'Kane says.

More than 6 in 10 Americans who receive health coverage through their employer are enrolled in PPOs, up from less than 40 percent 10 years ago.

"This year, we had much more widespread reporting from Medicare PPOs, which accounts for a fair part of the increase," says Jeff Van Ness, an NCQA spokesman. As a result of the increase in reporting, the NCQA is able to report on 22 HEDIS measures of clinical quality for PPO plans and eight measures of consumer experience.

"But it's not just that there were more PPOs reporting back," says Van Ness. "PPOs that had reported on a partial set of HEDIS measures in 2006 are now reporting on a full set of data measures in 2007. The data are much more robust — even data reported by the same plans year after year."

Interest in PPO quality reporting has expanded to the public sector as well, according to the report. The Medicare program and the federal Office of Personnel Management now require PPO plans to engage in HEDIS reporting.

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.