Whether it marked decisive support for managed care or a simple reluctance to authorize abrupt change, voters in California and Oregon turned down several ballot initiatives Nov. 5 that would have placed crippling restrictions on managed care plans. California residents resoundingly rejected two highly publicized initiatives that called for the imposition of extensive regulations and additional costs on HMOs and other managed care plans. Both California initiatives would have limited physician compensation arrangements, set minimum staffing levels at hospitals and other health facilities, restricted circumstances under which providers could be removed from a plan's network and required disclosure of certain health plan operational data.

"The side of reason has prevailed," declares Alan Hillman, M.D., director of the Center for Health Policy at the University of Pennsylvania's Leonard Davis Institute of Health Economics, encouraged by the recent vote. In making this "wise choice," he says, the voters "decided to let managed care evolve a bit more and to protect it from the kind of incrementalist potshots that would undermine certain aspects of it."

When the votes were counted, 58 percent of California voters rejected Proposition 214, sponsored by the Service Employees International Union. Proposition 216, offered by the California Nurses Association and the Foundation for Taxpayer and Consumer Rights, also was solidly defeated, with 62 percent of the state's residents voting No. The more onerous of the two, Proposition 216 also called for several billion dollars in new fees and taxes on health care businesses.

The California Association of HMOs (CAHMO) was especially pleased with the vote, which it contends sends a signal that voters are generally satisfied with their health coverage and health care service. "For the past three consecutive general elections, California voters have rejected bogus, special-interest health care 'reform' proposals," says Myra Snyder, CAHMO's president and CEO.

In 1992, residents in the state rejected a "play or pay" employer mandate initiative. Two years later, they voted down a single-payer ballot measure.

"Clearly, the message from California voters," says Snyder, "is that they do not want health care reform proposals that do little to improve access to health care, or that increase costs resulting in more government burdens on taxpayers."

Nevertheless, the issues behind the two California initiatives are not expected to fade away. Supporters will likely push for a bill covering some of the same points in the next legislative session. A spokesman for the National Conference of State Legislatures notes that the backers of the two measures have "raised the visibility" of the concerns consumers have about managed care .

Also aware of these concerns, managed care plans will continue to undertake quality studies and to educate consumers concerning "what man- aged care is all about," says CAHMO's Alan Tomiyama.

In Oregon, voters also rejected a highly publicized anti-managed care initiative spearheaded by Gordon Miller, a Salem ophthalmologist (see Managed Care's cover article, November). The measure would have allowed just five forms of reimbursement, effectively banning capitation as a method of provider payment.

On another ballot initiative, Oregon voters approved a measure giving the state government authority to raise Oregon's tobacco taxes to fund its health plan and tobacco-use reduction programs.

In Arizona, voters gave the state's Medicaid managed care system a boost by approving Proposition 203. It will add from 150,000 to 180,000 new enrollees to the system, and set aside $17 million a year from lottery proceeds for health programs. — Joan Szabo

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.