Not everybody believes that accountable care organizations (ACOs), a bulwark of the Affordable Care Act, will ride to medicine’s rescue. In fact, in these pages, well-known policy experts such as Regina Herzlinger, PhD, of Harvard Business School, and David J. Brailer, MD, PhD, the health technology czar under President George W. Bush, have been downright dismissive (http://tinyurl.com/herzlinger-view and http://tinyurl.com/brailer-interview, respectively). In fact, Brailer told us, “Accountable care organizations are a publicity stunt created by Congress and the administration to make people feel like they were reforming care delivery when everyone knew they weren’t.”

So, pressure’s on for those trying to make ACOs function. A study in the January issue of the Journal of Managed Care Pharmacy looks at how 46 ACOs handle pharmacy. They do a few things well, but some areas need improvement. For instance, only 9% are good at notifying a doctor when a prescription has been filled.

“Developing the capabilities to support, monitor, and ensure appropriate medication use will be critical to optimal patient outcomes and ACO success,” the authors say.

What are ACOs doing?
Percentage of 175 members of the American Medical Group Association that consider themselves highly ready to undertake each operation
Transmit prescriptions electronically70%
View prescription and medical data in single system54%
Encourage appropriate generic use with formularies50%
Identify potential drug-drug, drug-disease, and/or polypharmacy concerns43%
Use visit summaries to list all Rx, potential adverse reactions, and clear directions for use41%
Synchronize formularies across different care sites35%
Alert providers of preventive care gaps28%
Involve pharmacist in direct patient care22%
Balance financial incentives with quality metrics for a diversity of conditions22%
Notify care providers when Rx is prescribed20%
Implement protocols to avoid duplicate medications/polypharmacy17%
Capture patient-reported outcomes electronically15%
Share potential drug-drug/drug-disease/polypharmacy concerns with care team13%
Educate patients about alternatives/implications when determining the recommended medication care team11%
Notify care providers when Rx is filled9%
Quantify medication cost offsets7%
Source: “Are ACOs Ready to be Accountable for Medication Use?” Journal of Managed Care Pharmacy, January 2014

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.