October 2016

CMS’ Oncology Care Model program is bringing bundled payments to cancer care. With drug costs so high and hard to control, the 195 participating practices will have to figure out other ways to control costs if they want to beat financial benchmarks and earn bonuses.
Thomas Reinke
Current versions by ASCO, NCCN, and others may not be right for insurers, but they are eyeing new ways to crunch the numbers for cost and outcomes.
Ed Silverman
Experts are rethinking the routine cancer screen. In the future, screening recommendations may be tailored, risk-stratified, and based on our genes.
Charlotte Huff
Patients and doctors are fighting the urge to rush in and treat cancer right away. Insurers must walk a fine line.
Richard Mark Kirkner
The intrepid young oncologist’s criticism of cancer screening and surrogate endpoints has stirred up controversy. He says he just wants drugmakers, others to meet high standards of evidence.
Interview by Peter Wehrwein
Success in the Medicare Stars ratings system requires a culture that looks beyond short-term success to ensure long-term survival.
Vanessa Pawlak



Departments
Tomorrow’s Medicine
Carbon fiber is more flexible than metal, so it may help fractured bones heal faster. Carbon fiber hardware may also have an application in oncology.
Thomas Morrow, MD
Legislation & Regulation: Campaign 2016
The fate of the health care reform law will be determined by the outcome of a joyless election.
Richard Mark Kirkner
Costs Cast Shadow on Optimism About Treatment
Viewpoint
He has other serious health problems and needs a clinician to quarterback the care for all his conditions—not just the cancer.
Zachary Hafner

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.