In a study of seven industrialized countries, the United States came in last overall in health system performance, despite having the most expensive health care system. A new Commonwealth Fund report looks at measures of health system performance in five key areas: quality, efficiency, access to care, equity, and the ability to lead long, healthy, productive lives. The other countries ahead of us are Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom. The report says the United States does not get good value for its health care dollars, ranking last despite spending $7,290 per capita on health care in 2007, compared with $3,837 in the Netherlands, which ranked first overall. Commonwealth Fund president and lead author Karen Davis says the findings were “disappointing but not surprising,” but she thinks with the passage of the Patient Protection and Affordable Care Act the U.S. can begin “strengthening primary care and investing in health information technology and quality improvement”.... “One in five medical claims is processed by insurers with errors,” says Nancy H. Nielson, MD, immediate past president of the American Medical Association (AMA). This is echoed by findings from that group’s “National Health Insurer Report Card.” According to the AMA’s findings, the health industry as a whole has about an 80 percent accuracy rate for processing and paying claims. Of the seven insurers reviewed, Coventry Health Care came out on top, with a national accuracy rating of 88.4 percent. Anthem Blue Cross Blue Shield came in last at 74 percent. The seven insurers were Aetna, Anthem BCBS, Cigna, Coventry, Health Care Services Corp., and UnitedHealth Group.... The nation’s employers can expect medical costs to increase by 9 percent in 2011, a decrease of half a percentage point from the 2010 growth rate, according to a recent report issued by the PricewaterhouseCoopers Health Research Institute. For the first time, a majority of the American workforce will have a health insurance deductible of $400 or more, as more employers return to indemnity-style cost-sharing by raising out-of-pocket limits, replacing copayments with coinsurance, and adding high-deductible health plans.

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.