The United Kingdom’s National Health Service came under fire recently when it chose one vaccine to prevent cervical cancer over a rival. The vaccine program, which will protect young girls who might develop cervical cancer later in life, will dispense Cervarix, a vaccine that offers immunity to human papilloma virus (HPV) types 16 and 18, which are responsible for 70 percent of cases of cervical cancer. However, some experts say the agency should have chosen Gardasil, which besides protecting girls from HPV type 16 and 18, also provides protection against two other strains that can cause genital warts. A spokesperson for the NHS says, “The contract has been awarded for the vaccine that scored best overall against a number of pre-agreed criteria and offers best overall value to the NHS.”. . . Among national payers, Aetna pays providers the fastest, according to a survey conducted by Athenahealth. The survey used claims from more than 12,000 medical providers. It ranks health insurers according to specific measures of financial and administrative performance and on medical policy complexity. The five with the fastest remittance times were Aetna, Humana, Cigna, Medicare Part B, and UnitedHealth, in that order… Consumer Reports is launching a health ratings service that will add ratings for hospitals and health care providers to its current ranking of health-related products, treatment options, natural medications, and drugs. The first undertaking is a Web tool created in conjunction with the Dartmouth Atlas Project (see our Plan Watch column on page 53) that will allow consumers to compare treatment approaches among hospitals for nine chronic conditions. The rankings can be found at health/doctors-and-hospitals/ hospital-home.htm.

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.