Forget about pills and diets. Metabolic and bariatric surgery (MBS) most effectively treats obesity and the diseases and conditions that go with it. Providing a safe environment for these types of procedures has encouraged the American Society for Metabolic and Bariatric Surgery (ASMBS) to join the American College of Surgeons (ACS) in streamlining the accreditation process and developing outcomes benchmarks.

On April 1, they unified their MBS accreditation programs.

“This will bring 621 approved [surgery centers] together and we will all be using the same data registry to provide enhanced patient safety,” says Robin Blackstone, MD, president of ASMBS. “For a specialty society like ours to join with the ACS strengthens the environment for patient safety.”

Medicaid and state employee health plans cover MBS about 90 percent of the time, says Blackstone. Small employers (10–499 employees) cover it 40 percent; large employers (>20,000 employees), 75 percent.

“As the effectiveness of MBS has become more well-known, it’s been covered more,” says Blackstone. “The question has been, with obesity affecting so many people, how do you achieve a universal benefit for obesity treatment? What you want is the most effective therapy with the least complications. That gives insurers the best value.”

About 200,000 MBS procedures are performed each year in the United States, costing from $11,000 to $26,000 each, according to the ASMBS. Value does indeed matter, as Blackstone says. The two organizations will not only merge their accreditation processes, but overhaul them as well.

“This new unified program will at first be organized around accreditation based on volume, but will be updated to reflect accreditation based on outcomes,” says Blackstone. “All of our programs will be able to access the database” to improve quality

For instance, MBS program directors will be able to track the incidence and causes of readmissions, and work to ensure that systems are in place, or that changes are made, to decrease readmissions, says Blackstone.

The college and ASMBS hope to meet with a broad spectrum of insurance company officials, including medical and pharmacy directors, sometime in the next few months to get feedback on the new accreditation standards, says Blackstone.

“What we’re hoping is that all of the payers will recognize the value of this type of outcomes reporting and data registry reporting and really get behind having this one standard and supporting it,” says Blackstone.

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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.