Cancer care is becoming increasingly personalized. In one cancer after another, science is yielding discoveries about genetic mutations that affect survival and treatment outcomes. These discoveries are both prognostic, indicating tumor aggressiveness, and predictive, forecasting treatment efficacy.

These discoveries have led to better survival and smarter treatment in some once-hopeless diagnoses. A decade ago, 80 percent of patients with metastatic melanoma lived less than one year after diagnosis. Today, the one-year survival rate is 60 percent, thanks to the discovery of the BRAF mutation and therapies that target it. Similarly, lung cancer is no longer a one-size-fits-all diagnosis; 60 percent of non–small-cell lung cancers have a known genetic driver that guides treatment selection. Lung cancers in nonsmokers often respond well to targeted therapies, but those in smokers tend to have a different molecular makeup and rarely respond to any treatment regimen.

National Comprehensive Cancer Network guidelines include more than 600 molecular tests to guide treatment selection, yet an NCCN survey shows that molecular testing isn’t yet standard practice in oncology. Nearly 3 in 10 oncologists rarely or never perform molecular testing when prescribing targeted therapies.

Among clinicians who do order molecular diagnostic tests, the reasons are varied. Respondents to a separate NCCN survey said that the most frequent reasons for ordering a test were the evidence supporting its use and its specific use. Only 35 percent placed importance on a payer requirement that a test be performed before a targeted agent is prescribed. — Michael D. Dalzell

Frequency of companion diagnostic testing


Source: NCCN Trends: An Evaluation of the Use of Companion Diagnostic Testing and Targeted Therapies. National Comprehensive Cancer Network, Fort Washington, Pa., Feb. 11, 2013.

What information is important to clinicians about molecular tests?


Source: Engstrom PF, et al. NCCN Molecular Testing White Paper: Effectiveness, Efficiency, and Reimbursement. JNCCN. 2011;9(suppl 6):S1–S16.

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.