John Marcille

Our recent cover story shows how some health plan executives favor clinical decision support systems over utilization management to better control costs and improve doctor performance. CDS, they argue, seems to work better in a changing world in which the financial risk of delivering care shifts from insurers to the kinds of entities in which physicians play a larger role. Too often patients will demand, for example, scans that a doctor knows will not help. CDS helps the doctor to make the correct choice and then to explain to the patient why the scans shouldn’t be done.

Pat Courneya, MD, a senior medical director at HealthPartners, a health plan and care delivery system in Minnesota, sang CDS’s praises to contributing editor Joseph Burns. Courneya says that “we have seen that decision support as a tool has led to an essential flattening of the cost trend in high-tech imaging since 2007, greater satisfaction among providers and patients on the front lines of care, and a more direct path to answers to the questions clinicians and patients are asking about their conditions.”

Steven Gerst, MD, of MedCurrent, a company that supplies CDS systems, says that plans could save “1 to 3 percent on their administrative costs by leveraging the CDS technologies now available.”

OK, you’d expect a vendor to tout CDS, but Uncle Sam is interested as well. The Centers for Medicare & Medicaid Services (CMS) began a two-year demonstration project this summer to test whether the use of CDS can improve the quality of care and reduce unnecessary radiation exposure and utilization.

CMS plans to use the data from this project to assess the effect that using CDS has on the appropriateness and utilization of advanced medical imaging services ordered for Medicare fee-for-service patients. These systems, if they work out, should be a boon to plan, physician, and patient.

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.