Nearly 12 million patients a year are misdiagnosed, and half of those cases could lead to serious health problems, according to a meta-analysis in the journal BMJ Quality & Safety.

Researchers looked at three studies: one of misdiagnosis in primary care settings, and one each for colorectal cancer and for lung cancer that examine screenings and subsequent diagnosis.

The meta-analysis estimates “the frequency of diagnostic error to be at least 5% in U.S. outpatient adults, a number that entails a substantial patient safety risk. This population-based estimate should provide a foundation for policymakers, health care organizations, and researchers to strengthen efforts to measure and reduce diagnostic errors.”

The triggers in the primary care study were unplanned hospitalizations or unscheduled return visits within 14 days of the original visit.

“Although we presumed that the types of errors detected in the primary care study were likely to account for the majority of outpatient diagnostic errors, we also aimed to estimate the rate of errors related to initial diagnosis of less common but serious chronic conditions,” the study states.

Hence, the review of colorectal and lung cancer misdiagnosis. “Unlike misdiagnosis of acute conditions, these errors may not become apparent for weeks or months.”

Red flags were missed. For colorectal cancer this meant a “lack of follow-up 60 days after documentation of hematochezia (bright red blood per rectum), positive fecal occult blood test, and iron deficiency anemia.

“For lung cancer, we defined lack of follow-up as failure to initiate further investigation or an appropriate action within seven days of a documented red flag, such as an abnormal chest X-ray.”

The contribution of the two cancers to the overall estimation of missed diagnoses was small, “but we believe it was important to include them to show their relative contribution. This is because delayed cancer diagnosis is believed to be one of the most harmful and costly types of diagnostic error in the outpatient setting and its significance had become apparent not only in malpractice claims but also in retrospective studies of consecutive cancer cases, surveys, and studies of failures to follow-up abnormal test results.”

What can insurers do? Hardeep Singh, MD, MPH, the study’s corresponding author, says health plans “could work with researchers to identify care patterns in electronic data that suggest … diagnostic errors.”

Singh, a researcher at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine in Hous–ton, says that more evaluation must be done to “bring these triggers to real-world practice, but this is a start. In the future, such measurement techniques could help identify outliers in diagnostic performance.”

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.