Viewpoint
Jason Duhon
CMS depends on encounter data submitted by state Medicaid programs to maintain the massive Medicaid Statistical Information System (MSIS), a database of claims, encounter data, and beneficiary eligibility information. Poor encounter data can hinder quality measurement in multiple ways.
Measuring Quality
Joseph Burns

Peggy O’Kane

After 25 years, the Healthcare Effectiveness Data and Information Set (HEDIS) is still criticized for focusing on process and taking up doctors’ time. But it has been incorporated into physicians’ workflow and may yet be instrumental in bringing about value-based care.

There’s been much heated debate (but isn’t there always with this topic) about just what affect restrictive state abortion laws and the closing of abortion clinics have had on abortion rates, accordging to a report by the Guttmacher Institute, a research group that supports abortion rights It not

Measuring Quality
Thomas Reinke

Avedis Donabedian, MD

The measures most often used today to assess care quality are process measures. Actual outcomes, of course, are harder to measure than whether a certain action has been taken—checking the feet of a patient with diabetes, for example. But many experts don’t think process measures get at the heart of quality.

Thirty-two million people could find themselves uninsured by 2026 if President-elect Trump and Republican lawmakers don’t have something to replace the ACA with right away.

Measuring Quality
Richard Mark Kirkner
The problem, say hospitals and some analysts, is that rating hospital quality is not so straightforward. How a hospital delivers care is multifactorial and complex, they argue, so trying to cram that into a single score is misleading and can end up like rating a restaurant on its parking.

Close attention will be paid today as UnitedHealth Group reports its fourth quarter earnings, according to the Wall Street Journal.

CREs (carbapenem-resistant Enterobacteriaceae), the deadly bacteria that’s resistant to most antibiotics in the United States, is able to share its survival techniques to other families of bacteria that make up this grouping, according to a study in the Proceedings of the National Academy of Sciences (PNAS).

Q&A: The View From the Intermountain Top
Interview by Peter Wehrwein
Marc Harrison, MD
The new president and CEO of Intermountain looks ahead to the Utah system becoming a referral center and says last year’s net operating margin can be chalked up to an implementation of an electronic medical record system.
What To Expect in 2017: Managed Care Year in Preview
Jan Greene

Amazon Echo

Getting older people to bring a new technology into their homes has been more difficult than expected. Nevertheless, the tech industry continues to work on new options, and there are some intriguing possibilities on the horizon for 2017 and beyond.

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.