Once a sleepy system of indemnity insurers, the Blue Cross and Blue Shield network has awakened with the fervor of competition as its 63 plans strike deals with one another to gain muscle in the health care market.During May, three mergers made headlines. On May 3, Blue Cross of Northeastern Pennsylvania and Capital Blue Cross of Harrisburg revealed their plans to join forces. Nineteen days later, Blue Cross and Blue Shield plans in New Jersey and Delaware said they would merge. Ten more days and the New Jersey plan, not even close to completing its Delaware deal, said it would combine with Anthem Blue Cross and Blue Shield of Indiana to create a company with $7.8 billion annual income — Anthem's $6.1 billion, New Jersey's $1.3 billion and Delaware's $414 million.

"The rule of thumb today is that you need at least a million members to be competitive," said Robert Cole Jr., president and CEO of BCBS of Delaware. "Since there are only about 717,000 people in Delaware, it becomes impossible to achieve the scale required — even if we had one hundred percent of the market."

Being credentialed for the fifth or fifteenth time is a pain for physicians, and until the managed care industry standardizes the process it will continue to be dreaded. Offering some relief, so far only on a regional basis, is a working coalition of California associations representing physicians, medical groups and HMOs that has developed a credential form to replace redundant applications. It will be used throughout the state.

The form contains a core of questions for physicians about education, licensure, training and disciplinary and malpractice records. "In terms of hassle factors, having to fill out the same information over and over has probably been the number one issue among doctors," says John Lewin, M.D., CEO of the California Medical Association. "We're extremely pleased to have taken the lead in eliminating it."

Independently, Equifax, a major collector of personal credit and insurance data, has created an on-line system that will allow HMOs to get immediate verification of physician credentials. The Atlanta-based company says it has 600,000 doctors in its database. All the credentialing information, says Equifax, comes from primary sources.

Churning out five or six sets of clinical practice guidelines a year will not be the mission of the Agency for Health Care Policy and Research anymore. Agency Administrator Clifton Gaus, Sc.D., has been speaking with public and private groups for the past year and their message, he says, has been very clear: "They're seeking the scientific foundation from which they can develop their own high-quality, evidence-based guidelines."

To create this "scientific foundation," the six-year-old organization will work with states and groups such as HMOs and provider organizations to give them the tools to build guidelines that are better suited for their needs.

The agency will keep a national guideline database, contribute research and evaluation services and develop centers for evidence-based practice that will provide literature reviews, decision analyses and meta-analyses on topics of national interest.

Three sets of AHCPR guidelines are still in the works: colorectal cancer screening, chronic headache pain and Alzheimer's disease screening. Agency officials don't know when they will be released.

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.