“Look before you leap” might be the saddest phrase one can hear in free-fall, but it seems to be the advice given by the Agency for Healthcare Research and Quality regarding the patient-centered medical home.

“Primary care clinicians, health care systems, insurers, state governments, families, and communities” see PCMHs as a solution to many of the problems besetting the system, the AHRQ says in a report from Mathematica Policy Research, “Improving Evaluations of the Medical Home.” So much so that many stakeholders have already begun undertaking PCMH programs.

AHRQ reminds us that as implementers move forward, they must collect good data to direct future investments. “Strong evaluations are critical in determining whether the PCMH model works and for finding ways to refine, improve, customize, and disseminate the model if it does.”

Deborah Peikes, senior health researcher at Mathematica, says, “With such a wide variety of patient-centered medical home models, gathering and assessing the evidence on what’s working and where challenges arise is critical. The [report] describes why and how to commission effective evaluations. It also discusses which outcomes to assess, why to include comparison practices, and the importance of accounting for clustering of patients within practices.”

MANAGED CARE has long noted both the excitement and skepticism surrounding the PCMH model (/archives/2010/8/lessons-learned-building-patient-centered-medical-home). We’ve also reported on how some health plans have not hesitated to take up the challenge of designating a primary care doctor as chief care coordinator (/archives/2011/2/medical-home-common-ground-bcbsnc-and-provider-group).

The AHRQ and Mathematica Policy Research say that studies should account for clustering and focus more on increasing the number of practices rather than the number of patients.

“So that estimates of the effectiveness of interventions that alter the entire practice such as PCMH are not inflated, statistical corrections must be made for the degree to which patients in a practice tend to be more similar to each other than to patients in other practices (clustering),” states the report “Building the Evidence Base for the Medical Home: What Sample and Sample Size Do Studies Need?” (http://www.mathematica-mpr.com/publications/PDFs/health/evidencebase_medicalhome.pdf).

The white paper also says that having more patients per practice does little for the overall study and that “it is better to have many practices with few patients per practice than few practices with many patients in each. For example, a study with 100 practices and 20 patients per practice has much greater power than a study with 20 practices with 100 patients each.”

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.