NEJM Highlights March 2015: Progress against Crohn’s, PCSK9 inhibitors coming through, comparative effectiveness for diabetic macular edema, Eric Lander encourages the FDA on genomic testing regulation
A promising agent for Crohn’s Disease, a miserable illness Crohn’s is an inflammatory bowel disease that is notoriously unpredictable; flares can affect any part of the digestive tract and lead to grave complications. In this double-blind phase 2 study, patients were dosed with mongersen (licensed by Celgene) an anti-sense oligonucleotide that down-regulates the expression of a protein implicated in the inflammatory cascade. In general these classes of medications have to be given parenterally but in this case the target is the gut so it can be taken orally. At two weeks of treatment, the response rate was about 60% in the… Read More
A sizeable step forward but miles still to go: CMS’ Next Generation ACO model
CMS has issued a “Request for Applications” describing its Next Generation (NG) ACO. The model makes progress on three issues that have generated plenty of analytical handwringing from MedPAC and the broader ACO community. It also signals a strategy to set ACOs up to compete more directly with Medicare Advantage (MA). (1) Enhancing predictability The Medicare Shared Savings Program (MSSP) and Pioneer ACO models had different approaches to solving the same business parameters. With NG, CMS has generally picked the ones which enhance simplicity and predictability (see table). For example, Retrospective beneficiary reconciliation used by MSSP meant that… Read More
Biopharma innovation: Will there be sufficient incentives in the future?
Ezekiel Emanuel wrote an op-ed in the New York Times last month, which highlighted the low number of new antibiotics that have been brought to market in the past two decades. Antibiotics are a unique market compared to therapeutics for other diseases. Infectious disease clinicians prefer to use innovative new products as a last line of defense against highly resistant infections, relying on tried-and-true antibiotics as their primary options. Paradoxically, the “reward” for being a highly innovative, effective new antibiotic is to be sparsely used. Emanuel points out this conundrum while also highlighting the concurrent resistance to high prices, leading… Read More
NEJM Highlights February 2015: the most boring month in my NEJM reading memory
Our selection from a month with relatively few exciting articles – perhaps this long Boston winter has us all down. Precious metals and health plan buying: The implementation of the ACA has placed new decision making on individuals purchasing health insurance on the exchanges. In this report, the authors argue based on experiments that for many individuals, reversing the gold-silver-bronze nomenclature (gold becomes bronze and vice versa) reverses the preference independently of the underlying characteristics of the plans. For the public health advocate this highlights the need for educating shoppers, and also the need for… Read More
NEJM Highlights January 2015: Dengue vaccine, Informed consent, Cancer drugs and Tiering for selection
A vaccine for dengue finally nears the market Dengue is a mosquito transmitted viral infection that is often severe and occasionally fatal, and that has been identified as a growing public health threat, largely in the developing world but also with inroads in developed countries with hundreds of millions of cases yearly world-wide. At this time, there is no vaccine or treatment for dengue other than supportive care. In a placebo-controlled study, a dengue vaccine from Sanofi-Pasteur covering all 4 serotypes of dengue was found to be 60% efficacious in preventing disease, and 80% efficacious in preventing hospitalization from dengue raising… Read More
Cosgrove moves south: competitive implications of the formation of the Midwest Health Collaborative
A few days ago, Cleveland Clinic announced the formation of the Midwest Health Collaborative (“the Collaborative”), a new company jointly managed by six Ohio delivery systems across the state. The company’s goals are to share best practices, collaborate to reduce costs (e.g., procurement synergies) and “explore the business case” for developing a state-wide provider network. Notably, the deal was announced just eighteen months after Cleveland Clinic’s key competitor in Ohio, Mercy Health (formerly Catholic Health Partners), announced its own state-wide alliance, Health Innovations Ohio; this new deal also links three major southern Ohio provider systems (which directly compete with… Read More
Shifting lines in the mobile health competitive battlefield: Aetna makes a strategic retreat while United digs in?
The battle to own healthcare’s consumer relationship is being nowhere fought more intensely than in the mobile arena. Tea leaves suggest that Aetna has pulled back from trying to own this relationship in favor of a more collaborative “ecosystem” strategy, but United appears determined to lead. The thinking is speculative but I let me point out the emerging evidence and offer some guesses on what will come next. Strategy environment for consumer mobile health At the risk of oversimplification, let me offer six hypotheses regarding the strategic context for consumer mobile health: (1) The space is very much in… Read More
The “weaponization” of ACO narrow networks: Strategic destabilizers which compel their own replication?
In theory, narrow networks built around a single provider or a network of aligned providers (“provider-orchestrated narrow networks” or “ACO networks”) can pose a much higher stakes threat to non-participating providers than ones assembled solely by payers (i.e., where the payer picks who is in based on cost and rates): They are more likely to achieve broad utilization reduction because participating providers can align on principles, build shared capabilities and coordinate management of specific patients consistently. As a result, discounts can play a smaller role in creating a compelling value proposition for the plan sponsor, preserving better economics for the… Read More
Ochsner and River Parishes: one type of endgame for managing redundant hospital capacity (updated)
Please see update at end of post. If value-based care broadly delivers on its promise to reduce hospital admissions by providing more timely ambulatory care, a lot of today’s bed capacity will end up redundant and stranded. How can we navigate to a new equilibrium? Recent developments in the New Orleans area (whose population size still has not recovered from Katrina and is potentially therefore a model case of oversupply) may offer some window into future endgames for resolving the supply-demand imbalance. Acquire, unbundle, and selectively shut-down One approach is for an integrated system to acquire ailing assets, keep… Read More
Boeing’s model for creating product-based competition among providers
Summary Boeing is creating a benefit design model which sets up providers to compete for their book of lives via provider-branded narrow networks By offering a choice among competing narrow and full network products, the model may make narrow networks more palatable for employees Narrow networks can produce a volume windfall for providers (e.g., share gain, leakage reduction) and profits from better care management and a risk deal Providers “pay” for the narrow network opportunity by being lower cost (often via incremental discounts) in hopes that these gains outweigh cannibalization (profits lost on current patients who transition to the narrow… Read More