Insurers who recommend a particular provider or health care organization to a patient considering a surgical procedure need to determine how complex the procedure is and how frequently the surgeon performs the procedure.

If the procedure is fairly common, like bypass graft surgery or coronary artery surgery, chances are good that a high-volume provider and health care facility can deliver the best outcome.

However, some researchers and policymakers go so far as to recommend the regionalization of complex surgeries, arguing that by concentrating these surgeries at a few geographically dispersed high-volume facilities and eliminating low-volume facilities and providers, better patient outcomes can be expected.

Outcome data from hospitals in Florida, New Jersey, and New York suggest that patients who underwent a clinically complex operation called the Whipple technique, the most common surgical procedure for difficult-to-treat pancreatic cancer, "would be better off going to hospitals that perform this surgery often, rather than low-volume hospitals," says Vivian Ho, PhD, an associate professor of medicine at Baylor College of Medicine.

But limiting the number of providers also runs the risk of triggering a monopoly effect, says Ho.

Still, "When it comes to surgeries that involve very complex procedures, the higher benefit is seen if the procedure is performed by surgeons and hospitals that have performed more of them," says Ho.

"The managed care company needs to ask [of a hospital], 'How many procedures are performed at the facility and how many procedures has the surgeon performed?'" says Ho.

The study was published in the journal of Health Economics, Policy, and Law.

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.