The British Medical Journal this year published a comparison of Kaiser Permanente and the National Health Service, concluding that health care “costs per capita in Kaiser and the NHS are similar to within 10 percent and that Kaiser’s performance is considerably better in certain respects, particularly access to specialist diagnosis and treatment, and hospital waiting times."
Measure NHS Kaiser (California)
Primary care
Time to see a primary care physician 2001: average 3 days; <48 hours by 2004 Urgent: <24 hours; routine: 80% <7 days
Telephone help line and associated services NHS direct help line available. By 2004, NHS Direct will provide gateway to advice, appointments, and out of hours care. 24-hour hot line available for advice and appointments. Appointments can also be made online.
Repeat prescription available without calling or visiting a doctor Available nationwide by 2004 Available now
Time spent with primary care physician 8.8 minutes Medical: 20 minutes; Ob/Gyn: 15 minutes; pediatrics: 10 minutes
Specialist referral
Waiting time to see a specialist 2001: 36% <4 weeks, 20% >13 weeks, 4% >6 months; by 2005, average 5 weeks and maximum 3 months 2001: 80% <2 weeks
Waiting time for inpatient treatment or surgery 2001: 41% <13 weeks, 33% >5 months, 7% >12 months; by 2005: average 7 weeks and maximum 6 months 2001: 90% <13 weeks
Vaccination
Children who received various immunizations by 2 years old DTP=95%, MMR=88%, Hib=94% DTP=91%*, Polio=93%*, MMR=94%*, Hib=91%*, Hepatitis B=86%*, Chicken pox=83%*
Specialists per 100,000 people
Pediatricians 4.9 12.3
Ob/Gyn 4.1 8.3
Oncologists 0.9 1.7
Radiologists 4.3 6.0
Cardiologists 0.8 2.4
Cancer screening
Breast 69% of women age 50–64 had mammogram in past 3 years† 78% of women age 52–69 had ≥1 mammogram in the past 2 years*
Cervical 84% of women age 25–64 screened at least once in past 5 years‡ 80% of women age 21–64 screened at least once in past 3 years*
Diabetic care
People with diabetes who received annual retinal examination 60% 70% for <65 years;
80% for = 65 years
Coronary revascularization procedures per 100,000
Angioplasty 38** 116
Bypass graft 47** 127
Transplantation per 100,000
Heart 0.5 0.5
Kidney 2.7 4.8
*Data from Kaiser US (not California).
†2000, England.
‡1997, England.
**1998, England.

SOURCE: “GETTING MORE FOR THEIR DOLLAR: A COMPARISON OF THE NHS WITH CALIFORNIA’S KAISER,” BRITISH MEDICAL JOURNAL, JAN. 19, 2002

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.