Debate rationing

I read with great interest the interview with Leonard Fleck, PhD, in the August edition of MANAGED CARE. Fleck is entirely correct regarding the discussion of an honest broker to assess the effectiveness of diagnostic and therapeutic interventions.

Health plans cannot provide coverage decisions and care paths and enforce them. If they do, they risk being viewed as restricting or rationing care when a competitor may not. This puts the plan at a disadvantage in the marketplace.

There are some very easy savings to be obtained, such as mandating trial of a generic ACE inhibitor before an ARB for treatment of hypertension, with a savings of $3 billion. No PSA screening unless a digital rectal examination reveals an abnormality, with an estimated savings of $3 billion. Refuse to pay for home uterine activity monitoring for treatment of preterm labor because it is unproven after 20 years of use, with attendant savings of $10 million.

As Everett Dirksen, the late senator from Illinois, is credited with saying, a billion here and a billion there and pretty soon you’re talking real money! And these are just a few easy ones.

But health plans have difficulty going it alone or they risk market share losses. The American public truly does deserve honest debate on rationing, which in most cases is simply acting rationally.

James P. Reichmann, MBA
Senior vice president
American HomePatient
Brentwood, Tenn.

Misplaced priorities

While I admit many of the services encompassed by the Center for Medicare and Medicaid Innovation are needed, I am unsure if spending $10 billion and creating a new division with CMS is the way to go, as written in “$10B to Study Payment Systems,” September 2010. As I was reading Richard Mark Kirkner’s article, I couldn’t help but think about how the money could be better spent.

In sub-Saharan Africa alone it was estimated that 20.6 million adults and 1.8 million children were living with HIV/AIDS at the end of 2008 and 1.4 million people died from the disease that year.

Also, 14.1 million sub-Saharan children have lost one or both parents due to HIV/AIDS. It is estimated that 60 percent of children infected with HIV/AIDS in developing countries will die before their fifth birthday.

With the help of medications that are readily available in the U.S. and parts of Europe, the number of infections could come to a standstill and the number of deaths could decrease exponentially; however, in Africa, antiretroviral medications are scarce and come with a high price.

With what our government is spending on proper billing and payment of medical claims, countless adults and children could be saved from the HIV/AIDS epidemic that continues to spread worldwide.

Phillip W. McCreary, PharmD
Director of pharmacy
Spring View Hospital
Lebanon, Ky.

COEs are crucial

Re: “The Forces That Feed Medical Travel,” August 2010.

Despite the confusion over the definition of centers of excellence (COE), the concept is critical to payers. Plans are eager to identify centers that have superior outcomes and the potential to deliver greater value than others, even if it means sending the member to another location.

As plans drive transparency and providers embrace models like the patient-centered medical home, I expect more travel in the near future.

Derek VanAmerongen, MD
Cincinnati, Ohio

As a UnitedHealthcare medical director, I utilize COEs all the time.

Marshall Dawer, MD
Plano, Texas

Keep specialists out

Re: “Specialists Putting Mark on Strained Primary Care,” July 1010.

The problem with specialists entering the PCP [primary care physician] space is that they do so not because they wish to work in the holistic, patient-centered setting. They are in it solely for the money and therefore accountability is lacking.

Utilization of services will remain high. They may dabble in care but since they are not 100 percent investors in the concept, the patient will suffer.

We need to reward the PCP, keep the specialists out of primary care, and continue every effort to steer more students into family practice and internal medicine.

Bruce R. Croffy, MD, PhD
Chief medical officer
Blue Cross of Idaho

Trend line needed

Re.: “Drug Pipeline Loses Pressure,” August 2010.

A trend line with the number of new drugs by class in the pipeline would be interesting — oncology drugs, cardiovascular drugs, and so forth.

Blake Williamson, MD
Kansas City, Mo.

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.