Health plans accredited by the National Committee for Quality Assurance are twice as likely as nonaccredited plans to meet government standards for controlling blood pressure, according to the Morbidity and Mortality Weekly Report (, published by the Centers for Disease Control and Prevention. Controlled blood pressure is <140 mm Hg systolic and <90 mm Hg diastolic. About 67 million people in the United States have high blood pressure. An estimated 46,000 deaths could be avoided annually if 70% of patients with high blood pressure were treated, according to published guidelines.

In 2012, blood pressure was controlled in only 64% of members who were enrolled in HEDIS-reporting plans and who had diagnosed hypertension.The population comprises plan members ages 18–85 who had one or more outpatient encounters in which a diagnosis of hypertension that was not pregnancy-related or complicated by end-stage renal disease was recorded during the first six months of the measurement period.

While falling short of the 70% mark, it’s a slight improvement from 2010, and the change makes the MMWR authors think that the 70% goal might be achieved in the next few years. Modest improvements occurred in the 50th and 90th percentile plan-levels, the study says.

“The higher-performing plan categories are accredited commercial and Medicare Advantage HMOs, compared to the PPO population and Medicaid,” says Milesh M. Patel, MS, the lead author of the report.

Members with hypertension with controlled blood pressure by plan category, type, and year, according to HEDIS scores

Source: “Progress of Health Plans Toward Meeting the Million Hearts Clinical Target for High Blood Pressure Control – United States, 2010–2012,” Morbidity and Mortality Weekly Report, Feb. 14, 2014

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.