United HealthCare is investing heavily in the Southeast's managed care industry. The Minneapolis-based company intends to purchase HealthWise of America (not to be confused with Utah-based HealthWise, a Blue Cross and Blue Shield affiliate). HealthWise of America, based in Nashville, Tenn., operates HMOs with about 154,000 enrollees in Arkansas, Maryland, Kentucky and Tennessee, and plans to begin enrolling members in Virginia, where it has been granted an HMO license. It also hopes to expand into the nation's capital.

United HealthCare and HealthWise now compete in several markets. Whether to consolidate competing plans will be worked out in the future, say company officials.

Other recent purchases have boosted United HealthCare's Southeastern presence. In October it closed a deal to acquire MetraHealth, which operates in Maryland, Virginia, Kentucky and Washington, D.C., and covers 400,000 lives. After managing the business operations of PHP Inc. of Greensboro, N.C., for several years, United HealthCare absorbed the plan with a stock swap valued at $146 million. In Virginia, United HealthCare recently formed an alliance with the Medical Society of Virginia, with which it will create a statewide managed care plan.

The largest trade group representing the interests of managed care organizations has a new name. The entity formed by the September 1995 merger of the Group Health Association of America and the American Managed Care Review Association now calls itself the American Association of Health Plans, and has chosen a logo that is a semi-abstract image of two hands holding a globe. The Washington, D.C.-based organization's members include about 1,000 HMOs, preferred-provider organizations and other health plans.

— John A. Marcille, Paul Wynn


The benefits consulting firm Towers Perrin forecasts that large employers will pay 3 percent more for health care this year than they did last year, but they won't be able to blame HMOs. On average, there will be no increase in premiums for active employees in HMOs, and costs for retirees in HMOs will drop 3 percent. An individual's enrollment in a Medicare risk HMO can save an employer $1,000 a year.

SOURCE: TOWERS PERRIN, NEW YORK

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.