Through the years, academic researchers have collected, studied, sliced, and diced data from Medicare and Medicaid claims, but have often wished for greater access to private insurers’ treasure trove of data. Now a new initiative will give researchers and policymakers access to a comprehensive collection of health plan and government payer data that, one hopes, will offer insights into health care costs, utilization, and intensity.

Aetna, Humana, Kaiser Permanente, and UnitedHealth Group will provide information from more than five million claims that represent over $1 trillion in spending to the newly formed Health Care Cost Institute (HCCI). In addition to data from private insurers, HCCI will receive government data from the Medicare fee-for-service program and from Medicare Advantage. Importantly, to ensure usefulness, the data will be updated regularly.

Martin Gaynor, PhD, will head up HCCI, and says, “Unfortunately, the existing public data derived from Medicare and Medicaid activity aren’t enough to form a complete, up-to-date picture of national cost drivers and trends. For the first time there will be comprehensive data on the privately insured who make up the majority of health consumers in the United States.”

Gaynor says that Medicare represents only a third of people with insurance and that the program offers little information about the care being delivered to people under age 65 who are not covered.

HCCI says that identifiers will be stripped from the data in accordance with HIPAA regulations. The institute will establish a Data Integrity Committee whose primary focus will be on all matters related to data privacy, security, and integrity. Insurers will not have access to the aggregated pool of private data and the data will not be accessible to the public.

The claims will not be made available for commercial use, partly because officials want to prevent their use by any insurer negotiating with hospitals and doctors. The institute will provide claims data to qualified researchers seeking to analyze the data. Summaries that identify changes in health care prices and use of medical services will be made public twice a year, however.

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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.