Three quarters of health care leaders believe increased transparency — the public reporting of quality and pricing by name of hospital, physician practice, or health care provider — is essential to improve the performance of the United States’ health care system, according to the Commonwealth Fund/Modern Healthcare Health Opinion Leaders Survey. Improved transparency can affect health care costs, but only to a small degree, according to respondents.

Two-thirds of opinion leaders see improved transparency as a means of reducing health care spending, but opinion varies greatly on how large an effect transparency would have on cost. Seventeen percent say it will reduce spending by more than 5 percent, while 31 percent think it will reduce spending by 1 percent to 5 percent.

And transparency may be the “stick” in the “carrot and stick” model — 81 percent of respondents think that more widespread public reporting could stimulate providers to improve their performance, while increased transparency could also help patients make more informed decisions about their health care.

“Transparency is important because it motivates physicians and hospitals to assess and improve their care,” says Commonwealth Fund President Karen Davis. “For those providers who aren’t doing well, public reporting serves as a wake-up call to identify problems and improve performance.”

As with any new initiative, there are barriers to overcome. Respondents identified the logistical issues of collecting data and making information comparable across health plans and comprehensible to patients as potential obstacles to implementation. Survey respondents named the following as key strategies to improve health care quality and cost transparency:

  • Sharing the cost of data collection for performance measurement among providers, insurers, and the government (75%)
  • Ensuring widespread adoption of health information technology (88%)
  • Establishing a new public/private national entity to set standards for measurement and reporting and to be accountable for health system transparency (54%)
  • Paying providers based on publicly reported quality and price data (54%)

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.