John Marcille

An analysis in the New England Journal of Medicine (http://www.nejm.org/doi/full/10.1056/NEJMp0909947) February 18 about how the Dartmouth Atlas of Health Care rates hospitals has caught many eyes. Peter S. Bach, MD, a physician at Memorial Sloan-Kettering Cancer Center, posits that the Atlas uses flawed methodologies in suggesting that less is more. Dartmouth Atlas officials defend their methods in an addendum.

“Say Hospital A and Hospital B each has a group of patients with a fatal disease,” Bach writes. “Hospital A gives each patient a $1 pill and cures half of them; Hospital B provides no treatment. An Atlas analysis would conclude that Hospital B was more efficient, since it spent less per decedent. But all the patients die at Hospital B, whereas only half of the patients die at Hospital A, where the cost per life saved is a bargain at $2.”

In our cover story about disease management one of that industry’s boosters makes a similar point. Ariel Linden, DrPH, MS, a widely published researcher of DM outcomes, says that he is unable to find the extravagant savings that some DM vendors tout.

Linden favors a DM approach where the patient is managed in a primary care setting in an intensive — and expensive — manner. “Whoever said it was going to be cheap? I can’t understand this reasoning. Chronically ill patients are difficult, they’re sick, and they’ve spent most of their lives with unhealthy behaviors.”

Researchers are asking the same thing about hospital care. A University of Pittsburgh study finds that patients live longer at hospitals that offer the most intensive care (http://www.medicalnewstoday.com/releases/179017.php).

Is that the choice? Save lives or save money? Managed care will surely be drawn into this debate about where to draw the line.

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.