John Marcille

John Marcille

By now, most health-care decision makers are pretty well agreed that more care does not mean better care. And they also are agreed that when a provider charges a higher price, that is not necessarily related to the quality of the service.

But at the same time, we are greatly challenged by the fee-for-service method of payment and its perverse incentive to do more so as to be paid more. Of course the physician or the hospital would never order unneeded tests, procedures, drugs, images just to make money; you and I know that. Yet that CT scan might show something significant; that mammogram for a 40-year-old woman with no risk factors — it’s not as if youngish women never have breast cancer, now is it?

It’s rare that a health care story leads off the national network news broadcasts, but that’s what happened with the recommendation by the U.S. Preventive Services Task Force that the PSA test for prostate cancer not be performed routinely anymore for men of any age. This decision, long in the making, caps a long reassessment by the task force.

So, another instance of more but not better. (Yes, I know, urologists tend to disagree with the recommendation. Even my primary care doc isn’t going along with it, although he isn’t actually forcing me to take the test.)

On another, very promising front, in a program called Choosing Wisely, nine medical specialty societies recommended that physicians perform 45 common tests and procedures less often, and at least eight other specialty societies plan to join the movement in the fall. As our story by Managing Editor Frank Diamond points out, health plans have long been concerned and have subjected some of these to prior authorization.

Still, it’s good to know that insurers are no longer the only ones pointing to waste.

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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.