Advanced practice nurse practitioners (APRNs) want the Obama administration to make insurers accept them as legitimate primary care practitioners in the state health insurance exchanges. They say that despite laws in 17 states that allow them to practice independently, health plans still hesitate to include them in their provider panels. “As many more millions of uninsured or underinsured seek primary care services through these exchanges, they will need access to qualified primary care providers. That will not happen if private insurers continue to exclude or restrict APRNs from their provider networks,” says Karen Daley, president of the American Nurses Association.... Efforts to beef up the ranks of primary care physicians have gone online. A program called Physician Retraining & Reentry aims to help retired specialists brush up on their primary care skills and treat patients without having to return to medical school. Enrollees need to have a valid medical license.... The debate about how often mammographies should be given and to what demographic hasn’t been decided yet. About two thirds of breast cancer deaths in a longitudinal study between 1991 and 2007 occurred in women who had not had mammography. Their average age was 49. The findings, in the journal Cancer, are at odds with a controversial recommendation by the U.S. Preventive Services Task Force that routine mammographies begin at 50.... Severely obese children will burden health care spending in years to come unless something isn’t done to address recent trends, says the American Heart Association. About 4%–6% of children and adolescents in the United States fall into this category. In a 17-page statement, the AHA warns that “if left unchecked, it will have a profound effect on those it afflicts and will place a significant economic and clinical services burden on the future health care system.” Severely obese children over 2 have a body-mass index that’s 20% higher than the 95th percentile for their age and sex.

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.