Frank Diamond
Managing Editor

When I underwent hernia surgery years ago I pretended in the days leading up to the knife to shrug off the prospect. It was and is a minor outpatient procedure. A friend asked if I’d gotten any advice other than that given by my primary care physician and the attending surgeon. No, I said. She pointed out that “Surgeons like to cut. That’s what they do.”

Our cover story on shared decision making (SDM) reminded me of that instance. Author Joseph Burns reports how patients with benign prostatic hypertrophy were often left in the dark about some of the unwanted outcomes of the procedure, such as incontinence or impotence.

Now, “In a variety of clinical settings, electronic medical record systems alert physicians about the need to offer patients decision aids. Those aids may be videos seen on the Internet or distributed on DVD by mail.”

The technology is there, but so is the mindset. Federal regulations for accountable care organizations (ACOs) and meaningful use standards for electronic health records promote SDM as a way of more fully engaging patients. And indications are that they’ll need to be more fully engaged. A recent study finds that while baby boomers might live longer than their parents, they’re also sicker by a long shot.

Baby boomers — who, in the study, were people 46 to 64 between 2007 and 2010 — have higher cholesterol and blood pressure and suffer more from diabetes than did their parents.

While 32 percent of the older generation described their health as excellent, only 13 percent of baby boomers did, according to the study in the February issue of JAMA Internal Medicine. Baby boomers are also more likely to be obese and suffer from cancer and hypertension.

I saw no mention of hernias, but if the occasion should again arise I will probably talk to more than just my surgeon.

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.