By John Marcille

By John Marcille

A few years ago some enterprising writer decided to do a story that was so obvious that almost everybody else missed it. Go to a major league baseball game and you’ll see that the baseballs themselves are used and discarded with the frequency usually reserved for tissue paper during flu season. Does a ball have a nick or a scuffmark, or does it just not feel right to the pitcher? Then throw it away. That’s not counting the balls used for batting or fielding practice, or just having a catch. It’s been estimated that the average team uses between 35,000 to 55,000 balls a season, counting spring training and batting practice and everything else. Game balls last only about six pitches. It’s conceivable that Major League Baseball uses 1.7 million baseballs a year — a huge expense.

It pays to look closely at things. Managing Editor Frank Diamond’s cover story looks at the adage that “improving quality saves money.” So much of the processes that medical and pharmacy directors at health plans implement start with this assumption. Meanwhile, the idea’s main proselytizer over the last couple of decades, Donald M. Berwick, MD, is now the administrator of the Centers for Medicare & Medicaid Services. It’s no surprise, then, that much about health reform derives from the proposition that quality saves.

About 30 percent of what’s spent on health care is wasted, the theory goes. That 30 percent would more than pay for the upfront costs of providing quality care. Yet the 30 percent figure has always been a rough estimate, points out one of our Editorial Advisory Board members, Michael L. Millenson.

For certain, there have been sporadic instances in controlled settings in which it’s been documented that, to use the term from industry, “quality is free.” Is it, though? Is it really?

Just asking.

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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.