Sandra R. Parkington, MPH, RN
Quality Improvement Coordinator, Sharp Health Plan
Nora Faine, MD, MPH
Chief Medical Officer, Sharp Health Plan
Marcia C. Nguyen
Senior Data Analyst, Sharp Health Plan
Michelle T. Lowry, MPH
Quality Assistant, Sharp Health Plan
Poorva A. Virginkar
MHSA candidate 2009
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PURPOSE: In 2006, Sharp Health Plan (SHP) conducted a campaign to increase mammography screening for at-risk female members that consisted of mailing each eligible member an informational mammography postcard with an appointment tracker. Then came an automated phone call reminder. After the mammography campaign, 70 percent of SHP members sought mammography screening while 30 percent remained nonadherent. SHP decided to conduct a survey to better understand members’ barriers to breast cancer screening.

DESIGN: A survey based on Prochaska and Velicier’s Transtheoretical Model of Change was designed to assess members’ behavioral stage and barriers to breast cancer screening.

METHODOLOGY: The survey was administered to all nonadherent members via personal phone calls with nearly 50 percent of the nonadherent completing the interview. All quantitative data were examined, and a code book was created to assess additional qualitative data. Findings were further analyzed by stage of change, ethnicity/race, and region of San Diego.

PRINCIPAL FINDINGS: The top three barriers identified were: Mammogram not a priority, Knowledge deficit, and Had a bad experience in the past.

CONCLUSION: A common set of mammography barriers was found in the SHP member population. However, when segmented into ethnic, racial, geographic, and behavioral stage groups, various barriers were identified. SHP providers can use this information to develop more tailored interventions and to increase the rate of breast cancer screening for their member population.

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.