The first report issued by the Health Care Cost Institute made headlines last month not only for what it says but for how it came to say it.

“Health Care Cost and Utilization Report: 2010” crunches 3 billion claims for more than 33 million members of three of the biggest health plans: Aetna, Humana, and UnitedHealthcare. This is to be the first of many reports, and Kaiser Permanente will soon contribute to the data pool. Other insurers are welcome also. “These insurers have agreed, for the first time, to share their data with HCCI ....”

The report represents about 20 percent of all individuals with employer-sponsored health insurance. It does not rely on Medicare claim data that must be extrapolated to the larger population, as is historically the case with such studies.

“Few researchers have access to private claims data, and then generally from one commercial insurer,” the report states.

Some interesting findings off the bat: Utilization has indeed gone down, declining by over 5 percent from 2009 to 2010. Meanwhile, per capita spending increased by 3.3 percent in 2010.Why? Because of the prices that doctors and hospitals charge. It cost 6.4 percent more in 2010 than in 2009 for an inpatient surgical admission, and an ER visit was up 11 percent. Average facility price paid for outpatient surgery rose 8.9 percent.

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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.