John Marcille

“Our primary objective is to change the American public’s attitude that more is always better and physicians’ attitudes about their responsibility to be good managers of resources on behalf of their patients.”

Before you run for the exit, this is not a statement by an HMO executive circa 1996. It is, rather, the defense of an ever-widening and influential effort by doctors to police themselves through the Choosing Wisely campaign. It is offered by Daniel B. Wolfson, chief operating officer of the American Board of Internal Medicine Foundation, whose parent organization, the American Board of Internal Medicine (ABIM), spearheads the movement.

We noted in June 2012 how much of a game-changer this might be (http://tinyurl.com/choice-article). On February 21, the ABIM not only updated the list of overdone procedures (from 45 to 130), but updated the list of member organizations, adding 17.

You can get the lists here (http://tinyurl.com/doc-lists), but just to give you a taste:

  • The American Academy of Pediatrics says that children need not necessarily be given CT scans for minor head injuries. It recommends monitoring the patients before making that determination.
  • The American College of Obstetricians and Gynecologists says that annual Pap tests for women 30 to 65 need not be given. The tests should be given every three years.

Health insurance executives have been somewhat mute concerning this effort, perhaps recalling the visceral public reaction to rationing, perhaps thinking, Is it really worth it to deny someone a relatively inexpensive prostate-specific antigen test or mammogram? Maybe the answer, thankfully and at long last, is moot.

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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.