Erroneous diagnosis might be one of the most intransigent problems in health care, but it’s one that gets little attention, according to a study and commentary on the matter. “Health care leaders assume their physicians should be responsible for ensuring reliable diagnoses, but most physicians seem to believe they are doing just fine,” says a commentary in the Sept. 26, 2012 issue of the Journal of the American Medical Association. The authors — Mark L. Graber, MD, Robert M. Wachter, MD, and Christine K. Cassel, MD, MS — argue that misdiagnosis has been overlooked by experts trying to improve quality and safety (http://jamanetwork.com/journals/jama/fullarticle/1362034).

They point out that in To Err Is Human, the groundbreaking study by the Institute of Medicine, the phrase “medication error” is used 70 times while “diagnostic error” occurs only twice.

“Through malpractice suits, physicians are well aware of diagnostic error, but there is a general tendency to perceive that such errors are made by someone else, someone less careful or skillful,” the viewpoint states.

Nobody appears to be doing much about this, either.

“Moreover, whereas errors such as wrong-site surgery and wrong-dose medication errors seem amenable to systems solutions (time-outs, computerized order entry, etc.), diagnostic errors seem intensely personal: The ‘system’ appears to be the physician, and his or her own knowledge, skills, values, and behaviors.”

Through a chart review, researchers associated with the Houston Veterans Administration Medical Center looked at 190 misdiagnoses related to primary care. The most common were pneumonia (6.7 percent), decompensated congestive heart failure (5.7 percent), acute renal failure (5.3 percent), cancer (primary) (5.3 percent), and urinary tract infection or pyelonephritis (4.8 percent).

The study was published in the online edition of JAMA Internal Medicine (formerly Annals of Internal Medicine) on Feb. 23, and the results were alarming (http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1656540).

Most of the errors involve some sort of process breakdown or miscommunication between the primary care physician (PCP) and the patient.

“Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9 percent) but were also related to referrals (19.5 percent), patient-related factors (16.3 percent), follow-up and tracking of diagnostic information (14.7 percent), and performance and interpretation of diagnostic tests (13.7 percent),” says the study, “Types and Origins of Diagnostic Errors in Primary Care Settings.”

Hardeep Singh, MD, MPH, the lead author of the study tells Managed Care, “We are just now uncovering the underlying complexity of the problem, so anything I say today is likely to change down the road.”

He adds, “There are strategies health plans can use now, such as building reliable follow-up and tracking systems, which would be very useful. Because diagnosis evolves over time, I would encourage the clinician executives to explore how they could use their data to measure missed or delayed care especially in ambulatory settings.”

The study says that it is “not surprising that the primary care setting is vulnerable to medical errors.... However, data about the most frequent misdiagnosed conditions are scarce, and little is known about which diagnostic processes are most vulnerable to breakdown.”

The editorial by Graber, Wachter, and Cassel says, “We are unaware of any health care organization that is currently collecting specific data on diagnostic error or engaged in a systemwide campaign to decrease the frequency or consequences of diagnostic error.”

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.