The National Committee for Quality Assurance, in its never-ending effort to improve its own quality, wants to expand what the committee’s Healthcare Effectiveness Data and Information Set (HEDIS) measures look at in 2009.

As part of what the NCQA calls its “effectiveness of care” measure, the committee will review how well health plans immunize adolescents. Proposed is a measure to evaluate the percentage of adolescents who have one dose of meningococcal (MCV4 or MPSV4) vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), or diphtheria toxoids (Td) vaccine by the 13th birthday.

Perhaps to reinforce that health care is a cradle-to-grave endeavor, the NCQA also wants to tweak the way it measures the sort of care health plans provide older adults. The NCQA wants to know who, 65 or older, receives a functional status assessment, pain screening, advance care planning, and medication review during the measurement year.

The committee also wants to see how well plans track medication compliance by older people by measuring how many get their prescriptions filled after being discharged from the hospital.

In addition, the NCQA wants to find out how many adults, 18–74, have their body mass index measured. In the same vein, how many children, 2–17, have evidence of BMI percentile assessment, counseling for nutrition, and counseling for physical activity during the measurement year?

Those are the proposed new HEDIS measures. Meanwhile, the NCQA wants to tweak existing measures by adding diagnostic mammography to its breast cancer screening measure, adding hepatitis A, rotavirus, and influenza vaccines to its childhood immunization measure, and retiring the optimal practitioner contacts rate for its antidepressant medication management measure.

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.