One way of confronting growing costs is by accelerating bundled payment arrangements, according to a Commonwealth Fund study that looks at ways to slow down the rate of increases. “More-inclusive bundled payments in which a single payment is made for all care provided during an episode of care involving a hospital stay — including physician services — would provide incentives for teamwork and accountability for the total costs of care and outcomes associated with hospital episodes of care.”

The Commonwealth study, “Confronting Costs: Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System” (http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jan/Confronting-Costs.aspx), offers a wide range of approaches to do just as the title suggests. The goal is to hold health care spending to no more than “the rate of long-term growth in the economy while improving health care quality and outcomes.”

Among those approaches is bundled payment for acute care episodes. Bundling payment would “make it easier for patients as well as payers to compare and access the total costs of care and quality for certain procedures and conditions such as hip replacement surgery, appendectomy, or heart bypass surgery.”

Everybody agrees that something needs to be done. The cost of premiums already amounts to 23 percent of median family income. “If projected trends continue, the average premium for a family plan would exceed $24,000 by 2021 — the equivalent of 31 percent of median family income, intensifying pressure on family budgets across the country,” the study says.

Meanwhile, total business, household, and federal spending on health is expected to increase from $2.9 to $5.5 trillion in the next 10 years.

Health spending is a problem for the private sector as well as public programs. “While spending on publicly funded programs is currently a focal point of federal budget debates, for the past several years both Medicare and Medicaid spending per enrollee have been growing at rates well below spending for those who are privately insured.” The slower rate of growth for public programs is expected to continue over the next decade.

Medicare vs. employer-sponsored

Average annual per-capita increases, actual and projected

Average family premium as a percentage of median family income, 2013–2021

Projected national health expenditures by source, 2013–2023

Source: “Confronting Costs: Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System,” Commonwealth Fund, January 2013

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.