Medicare Part B covers 17 million ultrasound services provided in ambulatory settings to the tune of $2 billion, according to the Office of Inspector General (OIG) for the Department of Health & Human Services. It found a high concentration of ultrasound providers or services in certain counties. Its July report, Medicare Part B Billing for Ultrasound, suggests that this may indicate areas where Medicare’s safeguard efforts should be enhanced.

In 2007, 20 high-use counties accounted for 16 percent of Part B spending on ultrasound services despite having only 6 percent of Medicare beneficiaries, according to the report. The OIG also found 3.2 million claims with questionable characteristics that raise concerns about appropriateness.

In addition, beneficiaries in this small group of counties received a disproportionate number of services compared to beneficiaries in other counties. The OIG found that the average per-beneficiary spending on ultrasound services in the 20 high-use counties was more than three times what it was for beneficiaries in the rest of the country.

These are alarming patterns that have also been observed in the private sector, according to an America’s Health Insurance Plan’s (AHIP) white paper, Ensuring Quality Through Appropriate Use of Diagnostic Imaging, which reports that systemwide spending on high technology imaging is approaching $100 billion a year, and that it is expected to double over the next four years.

“Within our health care system, health plans often serve to identify and address emerging issues of patient safety and cost, and they set out to devise solutions to these problems,” says AHIP President Karen Ignagni. “The GAO report is a good illustration that the private sector is serving as an early warning system on critical quality, safety, and cost issues in the U.S. health care system.”

Health plans across the country have observed the trends documented in the GAO report and implemented radiology benefit management programs to address patient safety, quality, and waste.

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.