The biggest organizations involved in the health care system should lead the changes that are inevitably coming, says KPMG, the accounting, tax, and consulting firm. “Organizations are clearly considering the effectiveness of their fee-for-service business models, but migration to more value-based models will take some time, and will include a mix of old and new delivery and payment systems,” says Ed Giniat, KPMG’s national sector leader for health care and pharmaceuticals.

In other words, things can get sloppy as the Affordable Care Act encourages more mingling of health plans and providers, but Giniat says it doesn’t have to be that way. “The only way for more rapid integration to occur is for these stakeholders to lead the change and make it happen, but many of these organizations are using techniques more aligned with sustaining existing models.”

Survey data for “Transforming Healthcare: Emerging Business Models” were collected between January and June from 104 executives of hospital-led systems, 51 health plan executives, and 54 pharmaceutical company executives. Purchasers were not questioned.

Health plan executives expect that information technology, evidence-based medicine, disease management, and pay-for-performance incentives will be most effective in curbing costs. They are also concerned about large employers ceasing to offer insurance, say KPMG officials.

In response to cost shifting , health plans expect employers to demand lower costs and increased use of wellness and health management programs.

Likelihood of more integrated care delivery in the next 5 years

Expected employer response to cost shifting over next five years

Which cost-containment approaches will prove effective?

Source: “Transforming Healthcare: Emerging Business Models,” KPMG, Aug. 22, 2012

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.