The anti-managed care drive continues at the state level. State legislatures are zeroing in on the definition of "emergency services" by managed care plans, and their reimbursement policies for care delivered in emergency rooms. Concern is growing over reports of patients who have sought emergency room services and discovered after the fact that reimbursement for this care was denied by managed care plans that didn't think the patients' conditions were true emergencies.

In the 1996 legislative session, 23 states have introduced bills dealing with the emergency services controversy, according to the American Association of Health Plans' state tracking service. A number of states already have laws on the books, and others are expected to enact measures within the coming months. An emergency care provision is included in a comprehensive patient protection law recently enacted in Georgia. Effective July 1, the measure "will ultimately mean that more emergency room visits will be covered in the state," says David Cook, director of government relations for the Georgia Medical Association in Atlanta. It will require managed care companies to cover emergency room care if a "prudent lay person with an average knowledge of health believes that emergency care was needed." That is a fairly standard test used in these statutes, according to Ann Markus of George Washington University's Intergovernmental Health Policy Project.

The Georgia law also features a shopping list of other patient protection provisions including a ban on the use of financial incentives to deny necessary and appropriate care; a requirement for managed care companies to disclose benefits, exclusions, financial obligations, and lim- itations on providers, services, and prescription drugs, and a requirement for patient grievance procedures that offer a prompt and meaningful hearing. Arizona also recently enacted an emergency room service statute. Other states may follow the lead of the Peach and Grand Canyon states, experts say, especially if lawmakers continue to hear emergency room horror stories.

The spread of "telemedicine" — the use of electronic, audio and video communications technology to allow doctors to diagnose and consult with patients hundreds of miles away — is spurring regulatory concern in state legislatures. The National Governors' Association says roughly 30 states either have in place or are in the process of implementing telemedicine systems to increase rural access to specialists.

Telemedicine in effect allows physicians to practice in states where they are not licensed. To maintain standards of patient care and protect the public, the Federation of State Medical Boards in Euless, Texas, has drafted a model act requiring physicians who "regularly" practice telemedicine across state lines to obtain a "special purpose license."

The license would cover all forms of distant practice and would be issued to physicians holding full, unrestricted state licenses. Those who obtain a special license and engage in telemedicine must agree to be available to the issuing state's medical board and to provide any relevant records the board may need to investigate possible complaints.

California was the first state to propose legislation that closely resembles the FSMB's model act. South Dakota, Texas, Kansas, Oklahoma, and Nevada have restrictions against practicing interstate telemedicine without a license, and more states are expected to enact similar restrictions in the near future.

— 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.