Out-of-pocket expenditures are thought to be a significant barrier to receiving cancer preventive services, especially for individuals of lower socioeconomic status. A new study from the University Hospitals Cleveland Medical Center and the Case Comprehensive Cancer Center has looked at how the Patient Protection and Affordable Care Act (PPACA), which eliminated such out-of-pocket expenditures, affected the use of mammography and colonoscopy. Published online in Cancer, the study found that the use of mammography, but not colonoscopy, increased after the PPACA was passed.

To determine changes in the use of mammography and colonoscopy among fee-for-service Medicare beneficiaries before and after implementation of the PPACA, lead investigator Gregory Cooper, MD, and his colleagues examined Medicare claims data, identifying women 70 years of age and older without mammography during the previous two years and men and women in the same age group at increased risk for colorectal cancer without colonoscopy during the past five years. The team also identified patients who were screened in the two-year period before the PPACA’s implementation (2009 to 2010) and after its implementation (2011 to September 2012).

After out-of-pocket expenses for recommended cancer screening under the PPACA were eliminated, the uptake of mammography increased in all economic subgroups, including the poorest individuals. On the other hand, pre-existing disparities based on socioeconomic status in colonoscopy did not change. The investigators suspected that this might be due to other barriers related to colonoscopy, such as the need for bowel preparation or a loophole where a subset of colonoscopies still require out-of-pocket expenses.

“Although the future of the [PP]ACA is now questioned, the findings do support, at least for mammography, that elimination of financial barriers is associated with improvement in cancer screening,” Cooper said. “The findings have implications for other efforts to provide services to traditionally underserved patients, including the use of Medicaid expansion.”

At this point, it is not known which, if any, of the PPACA provisions will be continued under the new administration. Representative Tom Price, the nominee for head of the Department of Health and Human Services, had previously drafted a bill, the Empowering Patients First Act, that outlined proposed changes in health care; however, details of specific requirements for both private and government-funded insurance programs, including coverage for recommended preventive services, were not included in that plan.

Sources: Wiley; January 9, 2017; and Cancer; January 9, 2016.

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.