Between 50,000 to 100,000 deaths occur each year while millions of dollars are wasted on caring for conditions that could have been avoided, according to a report by the Centers for Disease Control and Prevention, the first in a series that will look at preventive care.

Health insurers offer a benchmark for how prevention should be handled, states “Rationale for Periodic Reporting on the Use of Selected Adult Clinical Preventive Services — United States,” published in the CDC’s Morbidity and Mortality Weekly Report (http://www.cdc.gov/mmwr/preview/ind2012_su.html).

“The health-related costs of underuse of recommended clinical preventive services are substantial,” the report states. “Researchers have reported that increasing use of nine clinical preventive services to more optimal levels (i.e., levels achieved by high-performing health plans) could prevent an estimated … annual loss in life expectancy for the U.S. population as a whole of approximately two million years.”

CDC Director Thomas R. Frieden, MD, MPH, wrote, “Tens of millions of people in the United States have not been benefiting from key preventive clinical services, and … there are large disparities by demographics, geography, and health care coverage and access in the provision of these services.”

The report, using data collected before 2010, finds that:

  • Slightly fewer than half of patients with heart disease are prescribed aspirin or other antiplatelet agents.
  • Slightly less than half of patients with high blood pressure had it under control.
  • Only two thirds of adults had had their cholesterol levels checked during the preceding five years.
  • More than one third of outpatient visits had no documentation of tobacco use status. “Rates of counseling were particularly low among younger smokers, despite a high level of interest in quitting in this population; younger smokers have been shown to be more likely to try to quit but less likely to succeed, hence could benefit particularly from improved counseling and treatment.”
  • About 2.3 million diabetics had poor glycemic control.
  • About 1 in 5 women between 50 and 75 had not had a mammogram during the preceding two years.
  • One third of people between 50 and 75 were not up to date with screening for colorectal cancer.
  • About 1 in 5 of the 1.1 million people in the United States living with HIV have not been diagnosed.
  • About 1 in 4 of people 65 and younger were vaccinated against influenza; 133 million adults were not vaccinated.

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.