PPOs are catching up to HMOs in quality, and the health insurance industry is improving quality overall, according to the latest State of Health Care Quality Report from the National Committee for Quality Assurance. The NCQA says that for the first time in the 15-year history of the annual survey, HMOs and PPOs are able to be compared using all measures of care. In the past, HMO performance outpaced PPO performance for several reasons: HMOs traditionally had more tools to manage care, differences in data collection or populations could be a factor, or benefit design might lend itself to better quality measurements.

Performance patterns between Medicare HMOs and PPOs are quite different. While HMOs outperform PPOs on some measures, PPOs outperform HMOs on several others, notably on measures related to drug therapy and monitoring. For example, with the HEDIS measure on “Pharmacological Management of COPD — Systemic Corticosteroids,” the average Medicare PPO rate is 69.6 percent and the average Medicare HMO rate is 66.6 percent.

Several measures showed important gains from 2009 to 2010, including “Colorectal Cancer Screening,” “Use of Spirometry Testing in the Assessment and Diagnosis of COPD,” and “Pharmacotherapy Management of COPD.” Commercial and Medicare PPOs displayed significant performance improvement and showed progress in closing the performance gap with HMOs.

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.