It’s not just the daunting challenges that occasionally defeat us. Sometimes plain old-fashioned inertia makes us hit the snooze button once too often. Our cover story leads with a challenge: “Almost immediately, hospitals could cut in half the number of infections that patients contract each year in health care facilities, but we lack the will or have failed to install the proper financial incentives to do so, experts say.”

Contributing editor Joseph Burns presents an in-depth package that looks at the problem of hospital-acquired infections (HAIs) and what can be done about it. Something’s already being done about it in some hospitals that have made ending HAIs such a priority that they are now near zero incidents. Other hospitals, though, not so good. Isn’t that the way it has always been in health care? There’s a wide disparity in quality.

Lives are at stake and no one shrugs, least of all clinician executives at health insurance companies. Their beneficiaries suffer, as well as their bottom lines. “Insurance companies could and should prioritize safety in hospitals more than they are doing,” says John Santa, MD, medical director of Consumer Reports.

There are success stories when it comes to developing systems. Thomas A. Scully, who ran CMS under President George W. Bush, tells us in our Q&A that two of the things he’s most proud of from his tenure are Medicare Advantage and Medicare Part D. Either because of politics or simply from honest evaluation, some may argue that these do not count as accomplishments. Fair enough, as even Scully would admit. He liked trying to get bipartisan approval and appreciates rational discussion and disagreement.

But that’s a debate for another venue. Suffice it to say here, though, that he did get things done. Take heart.

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.