In an ideal world, a patient’s continuity of care should be seamless when he is admitted to a hospital and when he is discharged. Managed care is supposed to step in and make that transition easier, but that isn’t the case, according to a recent study titled “Continuity of Outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults.”

“Health plans should make efforts to ensure communication between all the parties involved,” says Gulshan Sharma, MD, MPH, one of the authors. “This communication should occur both from PCP to hospitalist at admittance and from hospitalist to PCP during discharge, either by phone or electronic health record.” Sharma emphasizes that an obstacle to inpatient-outpatient management is lack of communication during the admission process and misunderstanding about who is responsible after discharge.

Sharma and his colleagues found that a patient in a hospital may be visited by a doctor he’s seen as an outpatient, but in 2006, that visit was less likely to happen than in 1996. In 1996, more than 50 percent of hospitalized patients were seen by at least one physician that they had visited in an outpatient setting in the previous year. In addition, 44 percent of patients with a regular physician were seen by that physician during their hospital stay.

By 2006, however, only 39.8 percent of patients received care from any physician that they had seen at least once in an outpatient setting before the hospitalization. Also, about 32 percent of patients with a regular physician were visited by that physician when hospitalized.

These decreases occurred in all areas of the country, in all types of hospitals, and for all diagnoses.

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.