Like the seasons, fiscal cycles are inexorable. No sooner had feuding Republicans and Democrats more or less decided to cool it on Medicare/Medicaid reform until after the election than the president sent the

1997 budget to the Hill — where it presumably will be tossed on top of its FY 1996 predecessor, which has yet to pass. In November, of course, Mr. Clinton vetoed the 1996 budget bill containing drastic Medicare/Medicaid reforms.

For '97, the Office of Management and Budget didn't crank out its customary forklifts full of budget documents. Instead, it Frisbeed the Hill a relative pamphlet called a "thematic document" purporting to balance the budget by 2002 and containing more than $100 million in tax cuts and spending slowdowns in Medicare.

For a while, the conservative House Democrats known as "Blue Dogs" have been saying that the biggest obstacle to turning Medicaid over to the states has been guaranteeing a minimum level of care. The GOP would have converted Medicaid into block grants to be spent at the discretion of each state. President Clinton would have maintained the program's overall structure but instituted capitated payments to slow program growth.

Seizing the initiative, the governors hammered out a compromise at their national meeting in February. Their plan would guarantee payment for hospital, physician and nursing facility services, home health care, family planning services, lab and X-ray services, pediatric and nursing facility services and diagnostic services for children. States would have "complete flexibility" to determine the amount, duration and scope of services and could use "all available" health care delivery systems without obtaining federal permission.

Don't count Medicaid reform out yet.

Meanwhile, many members of Congress don't want to report back to the voters in November with all health reforms stalemated. Still on the table are a simple portability bill in the House and the broader Senate bill introduced by lame-duck Republican Nancy Kassebaum of Kansas, co-sponsored by Massachusetts Democrat Edward M. Kennedy and approved unanimously by the Labor and Human Resources Committee last summer. The bill would assure access to insurance for workers laid off or taking early retirement if they had paid premiums for at least 18 months. It would limit pre-existing condition exclusions, prevent insurers from dropping coverage when a family member becomes ill and help companies form purchasing pools to cut insurance costs.

After some February horse trading there is good news and bad. The good is that the Senate is expected to debate Kassebaum-Kennedy in late April. The bad news is that unlimited amendments will be allowed, opening the door to riders from both sides of the aisle.

The National Committee for Quality Assurance released the Medicaid version of the Health Plan Employer Data and Information Set on Feb. 1. Although the Health Care Financing Administration is devising a single set of quality standards for both Medicare and Medicaid managed care plans, the joint standards will not be released until 1997. In the meantime, among other changes, plans using Medicaid HEDIS will now collect information on prenatal care utilization, but will no longer track cholesterol screening. For details, call NCQA at (202) 955-3500... Medicare plan-to-plan comparisons also being developed by HCFA are slated to be ready by Oct. 1, according to Bruce Fried, director of the office of managed care.

— Jean Lawrence

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.