Paul Wynn
MANAGED CARE January 1997. ©1997 Stezzi Communications

Like an assembly line grinding to a halt, the Agency for Health Care Policy and Research has manufactured its last set of regular clinical practice guidelines. The government-funded agency's future role in the guidelines-making arena will be to supply the scientific resources to help health plans, professional medical societies and other groups create guidelines of their own.

After creating 19 sets of guidelines on topics ranging from urinary incontinence to smoking cessation, the seven-year-old agency ended its work with guidelines addressing Alzheimer's disease, the most common form of dementia.

Alzheimer's disease-related dementia is a serious problem for an estimated 5 to 10 percent of the U.S. adult population 65 and older. Despite its prevalence, Alzheimer's disease is often misdiagnosed in the early stages or overlooked because memory loss is thought to be a natural result of old age. Dementia problems are disabling and "should not be viewed as an inevitable part of growing older," states the guidelines panel.

In about 20 percent of patients suffering from dementia symptoms, the cause is actually another treatable condition such as depression, alcoholism and even side effects from medications. Very often, depression can be difficult to distinguish from dementia, says T. Franklin Williams, M.D., professor of medicine emeritus, University of Rochester Medical Center, and panel co-chairman.

Diagnosing Alzheimer's disease can be extremely tricky. Making a proper diagnosis involves a multi-step approach that includes testing the patient's mental and functional ability and talking with the patient and family members.

Specific symptoms to look for include: difficulty with language, learning new things and retaining new information; unusual behavior, problems handling complex tasks, and disturbances of reasoning, spatial ability and orientation. Also, family histories of dementia or Down's syndrome are possible risk factors for Alzheimer's disease.

Background investigation

If there's some suspicion that a patient is having dementia, the 18-member guideline panel recommends physicians review the patient's history, conduct a physical exam, gather reports from family members or caregivers and do a brief mental status test and/or functional status assessment. For a diagnosis of dementia, consult the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Whenever possible, obtain history from both the patient and family members or close friends. These interviews can provide supplemental information about the likelihood of disease. The physical examination should include a short neurological evaluation.

There are several mental status tests to choose from, but none of them are meant to be diagnostic tools. Functional assessment can be performed with the Functional Activities Questionnaire, which evaluates day-to-day activities such as balancing a checkbook, shopping, playing games and preparing meals.

To order the guidelines, call or write AHCPR for the "Alzheimer's Disease Guidelines": (800) 358-9295 or AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.

Paul Wynn

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.