Paul Wynn

In the news:

Joint-Venture Plan in Virginia Allies Medical Society with United HealthCare

The 6,600-member Medical Society of Virginia has been searching for a managed care organization to work with for about a year. The society never considered a partnership with United HealthCare Corp. of Minneapolis. But in a strange turn of events, the two are forming a joint venture to develop a statewide managed care plan in Virginia.

Originally the society, which has about one-third primary care physicians, selected PHP Inc., of Greensboro, N.C., out of a field of 15 potential partners (United HealthCare was not on the list). Soon after PHP was picked, its management decided it wanted to sell the company. United HealthCare, which had managed PHP's business for years without having any ownership, was interested in buying.

The society decided to talk directly with United HealthCare and concluded that the company had a similar operating philosophy. Says the society's HMO committee chairman, thoracic surgeon C. Gregory Lockhart: "United HealthCare's emphasis on patient-directed care and doctor-patient relationships is why we approached them and formed a partnership."

The flagship product will be an open-access HMO, which officials expect will be available sometime in 1996. The decision to start other managed care plans will be driven by the marketplace, Lockhart says.

The joint venture will be United HealthCare's first HMO in Virginia. The company serves about 190,000 Virginians through indemnity plans that it acquired through its $1.65 billion purchase of MetraHealth.

Johns Hopkins Adds Affiliations

Rather than rest on their reputation, the medical centers and health system affiliated with Johns Hopkins University in Baltimore are aggressively signing deals to expand their primary care and specialty networks in Maryland, three surrounding states and the District of Columbia. "More than a year ago, Johns Hopkins decided it needed to develop a delivery system in parts of five states over the next several years," says Michele Deverich, vice president for network development at Johns Hopkins HealthCare.

JHHC, a joint venture between Johns Hopkins University School of Medicine and Johns Hopkins Health System, recently agreed to work with Humana Inc. to form physician networks throughout Maryland. As part of the deal, Johns Hopkins officials insisted that Humana use Johns Hopkins University as its sole academic center and employ nine central Maryland hospitals that Johns Hopkins works with through the Atlantic Health Alliance.

Together, the organizations will form specialty physician networks throughout Maryland. Johns Hopkins already has an eye network, a pediatric network and a primary care network that has many internists and a few family doctors. Humana's enrollees will be able to receive care through Johns Hopkins' networks and its hospitals.

On its own or through partnerships, Johns Hopkins HealthCare plans to expand its existing networks and develop new ones that would cover Maryland, Delaware, Washington, D.C., eight northern counties of Virginia and southern Pennsylvania, excluding Philadelphia.

Foundation Gives Grant To Study Medicaid Services

The Robert Wood Johnson Foundation has opened its wallet once more. This time the philanthropic organization has established a $21 million initiative to identify the best models for delivering managed care services to state Medicaid recipients.

The Health Care Financing Administration has granted waivers to a number of states to permit them to expand Medicaid managed care demonstration projects. But, says foundation President Steven A. Schroeder, M.D., "States have little experience in competitive purchasing for special needs populations, and this move into managed care means that the health care for millions of Americans hangs in the balance."

To address this concern, the foundation has started a program called "Strengthening the Safety Net: The Medicaid Managed Care Program." The initiative, which will be conducted by the nonpartisan group Center for Health Care Strategies, will award two grants and a technical assistance component.

Meanwhile, the Centers for Disease Control and Prevention has contracted with the Group Health Association of America/American Managed Care and Review Association to study, over five years, the ways in which managed care organizations can use preventive care to address public health problems. A consortium of health plans will be involved in the work.

The project also involves educating public health agencies and women's health organizations on managed care's preventive care approaches. GHAA/AMCRA will be paid about $4 million.

PPM Industry Continues its Consolidation

Physician practice management companies, which purchase practice assets and shoulder administrative duties for physicians, are experiencing growing pains like other segments of the health care industry. The largest PPM, Medpartners/Mullikin, formed from the merger between Medpartners and Mullikin Medical Enterprises in August, recently announced its desire to acquire Pacific Physician Services of Redlands, Calif.

The deal, valued at $332 million, would expand Medpartners/Mullikin's presence in the Southeast and Pacific Northwest. If the merger is approved by regulatory officials and the shareholders of both companies, the resulting entity will cover roughly 680,000 prepaid members.

Chart: In search of the ideal practice setting

More primary care physicians would choose to work as HMO or clinic employees than in solo practices, according to a recent survey of nearly 33,000 doctors. Groups and single-specialty networks are the favorite practice arrangements, the survey revealed. And when it comes to geography, warmer climes are favored over cooler ones.

SOURCE: Physician Services of America, Louisville, Ky.

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.