Back in 2002, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) examined the comparative value of different blood pressure-lowering medications. More than 33,000 patients were randomly assigned to take either a diuretic (chlorthalidone) or one of two newer drugs, a calcium channel blocker (amlodipine) or an ACE inhibitor (lisinopril). They followed these patients for four to eight years.

Researchers continued to follow these patients for an additional four to five years and the differences between the medications narrowed, but the diuretic was still superior in two measures: Patients taking the ACE inhibitor had a 20 percent higher death rate from stroke, and the calcium-channel blocker group had a 12 percent higher rate of hospitalizations and deaths caused by heart failure.

“Diuretics are a sensible starting point and an important component of any combination of drugs to help control hypertension,” says Paul Whelton, MD, president and CEO of Loyola University Health System and chairman of the ALLHAT study. “Concurrently, they are also very inexpensive.”

In the graph, chlorthalidone is the diuretic, amlodipine is the calcium channel blocker, and lisinopril is the ACE inhibitor.

Confidence intervals are used to indicate the reliability of an estimate, instead of using a single value.

CVD and all-cause mortality outcomes (95% CI)

Source: ALLHAT Collaborative Research Group. JAMA 2002;288:2981–97

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.