Hundreds of hospitals and thousands of physicians are participating in bundled payment programs, and most bundled payment contracts have upside and downside risk, according to François de Brantes, executive director of the Health Care Incentives Improvement Institute (HCI3). “We’re now in the scaling phase of this payment model and no longer in pilot or early stage,” he added.

In a report that HCI3 commissioned, the consultant Bailit Health Purchasing showed that both public and private payers are starting to use bundles as a core strategy to reform both payment and the delivery of care.

Bailit interviewed executives from six insurers and one Medicaid program and found three strong trends. First, the insurers were significantly expanding their bundled payment programs by including more providers and more conditions and episodes.

Second, they were automating resource-intensive processes that had been done manually, usually with spreadsheets.

To automate cost and reconciliation calculations, insurers are investing significantly in information systems from MedAssets, Optum, and TriZetto.

Through these investments, insurers may be demonstrating that bundling is effective at controlling costs, limiting complications, and improving quality.

Third, the insurers were simplifying their methods to make them easier to administer.

The 16-page report is based on interviews with executives from Aetna, Arkansas Medicaid, Arkansas Blue Cross and Blue Shield, Blue Cross and Blue Shield of North Carolina, Geisinger Health Plans, HealthNow New York, and Horizon Blue Cross Blue Shield of New Jersey.

The most common bundled procedures were hip and knee replacements. Less common were bundles for attention deficit hyperactivity disorder, coronary artery bypass graft surgery, colonoscopy, congestive heart failure, developmental disabilities, perinatal care, tonsillectomy, and upper respiratory infection.

One payer reported doing bundles for bariatric surgery and cataract removal, and another is doing adjuvant breast cancer and pregnancy.

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.