Nearly 60 percent of all surgical procedures take place in an ambulatory setting, where the patient receives less than 24 hours of hospital care, according to a recent report from the Agency for Healthcare Research and Quality (AHRQ). That’s good news to health plans, considering that the mean charge for ambulatory surgery is lower than for inpatient surgery — $6,100 versus $39,900. (Bold intended!) The study collected data from 28 states.

There are two factors that might explain the overall growth in ambulatory surgeries. First, surgery has become easier with advances in surgical technology and anesthesia. Second, health care payment policies encourage ambulatory surgery. For example, Medicare adopted an outpatient payment system authorizing payment for surgical services in a variety of settings, such as a physician’s office, a hospital outpatient department, or an ambulatory surgical center.

Characteristics of outpatient and inpatient surgeries
Characteristics Ambulatory surgeries Inpatient surgeries
Total visits/stays for surgeries (percentage of all surgical encounters) 10.8 million (57.7%) 7.9 million (42.3%)
Visits/stays per 100,000 population 5,600 4,100
Total number of surgeries (percentage of all surgical procedures) 12.4 million (53.0%) 11.0 million (47.0%)
Average number of surgeries per visit/stay 1.2 1.4
Total charge (percentage of total charges for surgical encounters) $55.6 billion (17.7%) $289.9 billion (82.3%)
Mean charge per visit/day $6,100 $39,900
Source: Agency for Healthcare Research and Quality. Statistical Brief #86, February 2010.

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.