Frank Diamond
Managing Editor

The costs of heart disease will go up substantially in the next decades. Using data from the National Health and Nutrition Examination Surveys to make the forecast, a recent study in Health Affairs (http://tinyurl.com/heart-data) predicts that the average 10-year risk of heart disease will rise about 15% for men and 9% for women by 2030, from a baseline of 12.7% and 6.8% in 1991.

Compliance, or lack of it, will play a huge role. The study says, “Pessimistic assumptions of 50% compliance with treatment resulted in 3 million additional cases of cardiovascular disease in 2030, compared to base-case assumption of 75% compliance.”

That’s a spread made big by the somewhat unpredictable factor of compliance with prevention methods. Take, for instance, cholesterol.

Data from the Centers for Disease Control and Prevention (http://tinyurl.com/CDC-data-brief) show that after improving in the last decade, total cholesterol levels remained constant over the last few years. The CDC would also like to see about 86% of Americans screened every five years. That number has remained stubbornly at about 70% since 1999.

Cholesterol screening rates, percentages, 2011-2012

NOTE: Screened for cholesterol is having cholesterol checked within the past 5 years.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.

There is some good news in the CDC data. Fewer Americans had low levels of HDL in 2010-2011 than in 2009–2010.

Percent who had low HDL cholesterol, 2011–2012

NOTES: HDL is high-density lipoprotein. Low HDL is <40 mg/dL.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.

Still, not quite what health officials want to see. “Although the percentage of adults aged 20 and over with high total cholesterol declined substantially from 1999 to 2010, there was no change between 2009–2010 and 2011–2012. There was also no change in the percentage of adults screened for cholesterol. ”

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.