John Marcille

John Marcille

Change isn’t always progress, but in this case, it surely is. The move to ICD-10’s vastly expanded set of disease and procedure codes is necessary because of the many changes in medicine and surgery that have taken place over the decades since the last true overhaul of the ICD code set over 60 years ago!

Yes, it’s about time. Our managing editor, Frank Diamond, in our article, examines many of the difficulties that lie ahead, starting with one that should be resolved very soon: whether the Centers for Medicare and Medicaid Services will stick to the Oct. 1, 2011 implementation date.

Frank discusses the challenges that health plans and payers will face in trying to implement the new ICD-10 codes. It’s a complicated process that will alter the most basic functions health plans perform, says Jim Daley, director of risk and compliance in the information systems department at Blue Cross & Blue Shield of South Carolina. He is a nationally known expert on the subject.

“Health plans look at certain conditions and say they should be treated in a certain way, or this is appropriate or not appropriate for a given condition,” he says. “Those decisions are based, obviously, on the medical condition, but also on the wording and the code associated with it.”

There have been minor changes over the years, but even so, it has been 27 years since the last upgrade to the International Statistical Classification of Diseases and Related Health Problems, and medicine has evolved far beyond ICD-9’s capacity to describe it.

Says Karen Trudel, the deputy director of the Office of E-Health Standards and Services at CMS: “Most parts of the health care industry agree that this needs to be done and that the real discussion is what’s the timing for it and that it’s a major undertaking.”

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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.