Good news for insurers and patients considering undergoing bariatric surgery: The Agency for Healthcare Research and Quality (AHRQ) found that the rate of post-surgical and other complications in patients who undergo the procedures declined 21 percent between 2002 and 2006. AHRQ, in the study “Recent Improvements in Bariatric Surgery Outcomes,” also found that payments to hospitals dropped by as much as 13 percent for bariatric surgery patients during that period. The agency explained this drop in part because fewer complications meant fewer readmissions.

The complication rate in patients initially hospitalized for this surgery declined to roughly 15 percent, attributable to a lowered post-surgical infection rate. Incidents of abdominal hernias, staple leakage, respiratory failure, and pneumonia fell between 50 percent and 29 percent.

Most of the improvement was in the initial hospital stay, where the risk-adjusted inpatient complication rate declined 37 percent, from 23.6 percent to 14.8 percent.

Hospital payments for these patients fell from $29,563 to $27,905. Even payments for patients who experienced complications dropped, from $41,807 to $38,175. Hospital payments for the most expensive patients — those who had to be readmitted because of complications — fell from $80,000 to $69,960.

The agency attributes this decline to greater experience of surgeons and hospitals.

Carolyn M. Clancy, MD, director of AHRQ, says that “all surgeries involve risks, but as newer technologies emerge and surgeons and hospitals gain experience, as this study shows, risks can decrease.”

AHRQ researchers looked at complication rates for more than 9,500 patients under age 65 who underwent obesity surgery at 652 hospitals between 2001 and 2002 and between 2005 and 2006. The researchers found that “the complication rate fell in spite of an increase in the percentage of older and sicker patients having the operation.”

Hospital readmissions because of complications fell 31 percent, while complication-caused same-day hospital outpatient clinic visits declined from about 15 percent to 13 percent.

William E. Encinosa, PhD, the AHRQ’s senior economist and lead author, says that the improvements are attributable to three factors — increased use of laparoscopy, increased use of banding procedures without gastric bypass, such as lap band, and increased surgeon experience arising from the increase in the number of bariatric surgeries performed by hospitals.

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.