Making hospitals pick up the tab for patients who are readmitted because of infections contracted in those facilities on a previous visit doesn’t seem to improve outcomes, says a study of a policy implemented by the Centers for Medicare & Medicaid Services several years ago.

“Effect of Nonpayment for Preventable Infections in U.S. Hospitals,” published in the Oct. 11, 2012 issue of the New England Journal of Medicine, says that the CMS had not been able to force hospitals to cut infection rates for central-catheter-associated bloodstream infections and catheter-associated urinary tract infections.

“Our models showed significant decreases in rates of central-catheter-associated bloodstream infections during the periods before implementation of the policy (4.8 percent per quarter) and after implementation (4.7 percent per quarter), with no measurable effect of the CMS policy on either the trend (incidence-rate ratio, 1.00; P=0.97) or the intercept (incidence-rate ratio, 0.95; P=0.75) in the post-implementation period versus the pre-implementation period,” the study says.

The CMS policy did not affect the catheter-associated urinary tract infections much either. The authors used data collected from 398 hospitals in 44 states from January 2006 to March 2011. “We found no evidence that the 2008 CMS policy to reduce payments for [the two types of infection] had any measurable effect on infection rates.”

The nonpayment initiative came about partly because of arguments that pay for performance doesn’t seem to work either. “… [D]espite widespread adoption of pay-for-performance programs by health plans over the past decade, the evidence that they improve patient outcomes, either in primary care settings or hospital settings, is mixed.”

They also question reports of P4P’s cost-effectiveness. “There are lingering concerns that pay for performance may lead providers to avoid the most seriously ill patients, which may mitigate any intended beneficial effect of these programs.”

In other words, P4P programs contain a perverse incentive.

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.