Implementing the New HEDIS Hypertension Performance Measure

This monograph, written in 2000 by Cary Sennett, MD, PhD, is a description of the National Committee for Quality Assurance's HEDIS hypertension measure, as promulgated that year. The material also includes a discussion of the importance of hypertension control and the need to monitor providers carefully. The implementation of this measure created challenges for health plans, in terms of both performance measurement and performance improvement. The information provided herein is intended to help leaders in managed care plans prepare for those challenges, by providing a greater understanding of the problem of hypertension control, then explaining how measurement can help improvement efforts, what strategies might be helpful, and what implementation might require. The article is drawn from a summit that brought researchers together with health plan medical directors, pharmacy directors, and quality assurance directors to share knowledge and develop recommendations for others.

Highlights:

  • The HEDIS Hypertension Measure
  • Implementing the Measure
  • Beyond HEDIS: Measuring Progress in Your Organization
  • Implications for Medical, Pharmacy, and Quality Assurance Directors

Treatment and Management of Type 2 Diabetes

Diabetes affects 16 million Americans at an annual cost of nearly $100 billion. One third of those with diabetes are undiagnosed, while a substantial portion of those with diagnosed disease are undertreated — with staggering clinical and economic implications. This supplement discusses pharmacological options for treatment, the National Committee for Quality Assurance’s role in helping health plans to provide adequate care for its diabetic members, and a case study of a successful diabetes disease management program. The information herein derives from a meeting attended by physicians, pharmacists, health plan medical and pharmacy directors, employers, pharmacy benefit managers, and quality assurance experts.

Highlights:

  • Diabetes Prevalence and Economic Implications
  • Comprehensive HEDIS Measures for Diabetic Patients
  • Management of Type 2 Diabetes: Update on New Pharmacological Options
  • A Disease Management Approach to Type 2 Diabetes
  • Roundtable Discussion: The Future of Diabetes Treatment

Compliance and Persistence With Medication Therapy

Patients' failure to adhere to medication regimens is a major problem. The factors that beget nonadherence are complex and interwoven. Patients' ability to understand their treatment routines or the reasons for them, side effects, financial barriers, simple forgetfulness — or any combination of these and myriad other determinants — can influence adherence to therapy. Removing barriers to adherence ultimately improves the potential for positive clinical and financial outcomes.

Highlights:

  • A Retrospective Study of Persistence With Single-Pill Combination Therapy vs. Concurrent Two-Pill Therapy in Patients With Hypertension
  • Medication Noncompliance: What Is the Problem?

Using Antiplatelet Agents To Lower Risk of Stroke and MI

Atherosclerosis is a contributing factor to heart attack, stroke, or peripheral arterial disease. These overlapping disease states are linked by common risk factors and a shared pathophysiologic factor, the platelet. Antiplatelet therapy, therefore, may help to reduce the risk of vascular events and thereby lessen the morbidity, mortality, and cost associated with atherosclerosis and its consequences. The material in this publication stems from a panel discussion of experts in neurology, cardiovascular medicine, and vascular medicine, along with representatives of leading MCOs. Their goal was to reach a consensus on use of antiplatelet therapy within a managed care environment. Clinical pathways for therapy related to myocardial infarction, stroke, and peripheral arterial disease were developed by consensus of the panel and are presented herein. Lawrence M. Brass, MD, of Yale University and Randall Zusman, MD, of Harvard University co-chaired the meeting.

Highlights:

  • Clinical and Economic Implications of Atherosclerosis
  • Antiplatelet Therapy: A Perspective From Cardiology
  • Antiplatelet Therapy: A Perspective From Vascular Medicine
  • Antiplatelet Therapy: A Perspective From Neurology

The Changing Landscape of Healthcare

Health care was one of the major themes of the 2000 presidential election season. The presentations at the 13th Annual Managed Healthcare Symposium, just prior to the 2000 election, capsulated the political, economic, and social implications of the health care issues that the current administration in Washington now faces and that are still relevant as the 2004 elections approach. These presentations, adapted for this supplement, include discussions of consumer expectations, the uninsured, Medicare reform, employer concerns, and a frank keynote debate between Paul Begala and Robert Novak. The important issues discussed in this supplement will be of interest to health plan medical and pharmacy directors, pharmacists, pharmacy benefit managers, employers, and quality assurance experts.

Highlights:

  • The Presidential Election and Its Effect on Health Care (Begala/Novak)
  • The Employer’s View of Health Care
  • Health Care in the Information Age
  • Issues That Will Determine Health Care’s Future
  • Panel Discussion: Solutions to Health Care Issues
  • Special motivational presentation: Humor, Risk, and Change

Payor, Provider, Patient: Healthcare by Consensus

With health care today being a collaborative effort among providers, patients, and payers, the paradigm of care delivery has changed. Providers want autonomy but are increasingly being held to evidence-based and population-based standards. Payers are demanding this accountability, but the managed care backlash has forced them to refrain from micromanaging providers. Many patients, meanwhile, see personalized health care as a right — even as employer cost-sharing tactics bestow patients with a responsibility to exercise cost-conscious decision making. The presentations in this supplement, derived from the 12th Annual Symposium for Managed Care Professionals, explore the issues inherent in this transforming environment.

Highlights:

  • Health Status, Health Maintenance, and Health Care in the 21st Century
  • Health Care Reform: Payer, Provider, Patient
  • Health Care Reform: The Consumer’s Viewpoint
  • Changing the Public’s Image of Managed Care
  • Treating Diseases and Managing Cost
  • Special motivational presentation: The Power of Perspective

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.