Words like “remarkable,” “exciting,” “very special,” and “huge impact” accompanied release of a study that classifies breast cancer into 10 different subgroups, a finding that can change the way the disease is diagnosed and treated. However, the ground-breaking research might make life more complicated for clinician executives at health insurance plans.

Just how groundbreaking are the findings? “Our work provides a definitive framework for understanding how gene copy number aberrations affect gene expression in breast cancer and reveals novel subgroups that should be the target of future investigation,” states “The Genomic and Transcriptomic Architecture of 2,000 Breast Tumours Reveals Novel Subgroups.” The study, published in the journal Nature, is the result of work by a research team at the University of Cambridge in Great Britain called the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC).

“It potentially complicates things for managed care organizations, which continue to have a fiduciary duty to match coverage of breast cancer to evidence-based appropriateness,” says Jaan Sidorov, MD, a consultant and member of MANAGED CARE’s Editorial Advisory Board. “Oncologists — who advocate on behalf of their patients — will need to work with and educate the managed care organization’s clinical staff on the rationale for the proposed treatments. It’ll take time — and patience — on both sides.”

The DNA and RNA of nearly 2,000 tumor samples were analyzed from between 5 and 10 years ago. “We present an integrated analysis of copy number and gene expression in a discovery and validation set of 997 and 995 primary breast tumours, respectively, with long-term clinical follow-up,” the study states.

Raju Kucherlapati, PhD, a genetics professor at Harvard Medical School (not part of the study team), tells the Los Angeles Times that “The fact that they have 997 samples for discovery and 995 for validation makes it very special.”

Time magazine reports that the new categories range from very treatable to extremely aggressive. “Because patient responses can’t be precisely predicted, it can lead to overtreatment, with doctors trying therapies even though the patient may not benefit. Having a more detailed system of tumor categories can not only help avoid that problem, but also tailor treatment to individual patients and predict women’s survival more accurately.”

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.