Back in med school, maybe even in undergraduate days, physicians learned of the inverse relationship between health status and income. The poorer someone is, the more likely he is to develop diabetes, cancer, or even a burst appendix. So it comes as no surprise that a study sponsored by the American Heart Association says that the odds of having heart failure are higher for elderly with low incomes.

Income is more a predictor than even education level. Someone with a college degree who happens to be poor seems to be more susceptible to heart failure than someone with a lower education level who is well off, says Ali Ahmed, MD, MPH, of the University of Alabama at Birmingham School of Medicine.

Ahmed unveiled his study at the American Heart Association’s Scientific Sessions 2011. According to the AHA, Ahmed’s study is the first to link low income with increased risk of heart failure in men and women of Medicare age. Those participants lived in the community, not in any hospital, clinic, or nursing home.

“We observed that community-dwelling Medicare-eligible older Americans with low annual household income of less than $25,000 who represent nearly half of all Medicare beneficiaries were more likely to develop heart failure or die, regardless of education,” says Ahmed.

Addressing this disparity would involve change in national policy, says Ahmed, but medical and pharmacy directors at health insurance plans don’t have to wait for such a major shift. For example, nearly 10 percent of the low-income Medicare beneficiaries do not have any prescription drug coverage, and it can be as high as 17 percent for those not receiving low-income subsidies.

“Providing low cost prescription drugs for low-income Medicare beneficiaries with cardiovascular risk factors such as hypertension or coronary artery disease will likely improve ... care for those conditions, which in turn will likely reduce the risk of incident heart failure and other cardiovascular events or death,” says Ahmed.

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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.