MANAGED CARE March 1997. ©1997 MediMedia USA

State legislatures and regulators are showing considerable interest in requiring managed care plans to provide continuity of care for patients with certain medical conditions. The aim is to avoid disruption in care when the physician can no longer see a patient because an employer changes health plans or because of an internal change in a plan.

Disruption in treatment often occurs when patients enroll in an HMO, must change HMOs, or are told that the physician they've seen for some time no longer contracts with their HMO. This is "not a problem if the individual is healthy,'' according to "HMO Consumers at Risk: States to the Rescue," a publication prepared by Families USA Foundation, a consumer health advocacy organization based in Washington, D.C. Difficulties arise, for example, if a person has cancer, is pregnant or has a degenerative condition.

Minnesota was the first state to require HMOs to grant a referral to a terminated provider if medical circumstances warrant. A number of states have begun to follow Minnesota's lead and more are expected to join them. Kansas, Maryland, Texas, Virginia and New York now have similar laws. New Jersey is expected to approve a continuity-of-care bill in the coming months, and New Mexico and Oregon will consider such a measure as well.

Both Kansas and Texas require managed care plans to continue care where medically necessary for up to 90 days following contract termination for both primary care physicians and specialists. Maryland and Virginia limit such requirements to primary care physicians, not specialists, for up to 60 days after termination of contracts.

Geraldine Dallek, director of health policy for Families USA, would like states to mandate at least 120 days of continued care by primary care and specialty providers when medically necessary.

Mental health parity laws are in place in seven states and on the legislative agenda in a dozen others.

Maine, Maryland, Minnesota, New Hampshire and Rhode Island require health plans to offer mental health treatment equal to that offered for physical illness. North Carolina and Texas require equal benefits for state and local government workers.

In the last legislative session, Louisiana, North Dakota, Oklahoma and Virginia voted to conduct studies of mental health parity.

A federal measure requiring health plans to set equal annual and lifetime limits for medical and mental health benefits was enacted last September, to take effect Jan. 1, 1998.

Managed behavioral health care companies say the law is likely to accelerate the trend toward managed mental health care as traditional indemnity plans seek to lower their costs. The new law, however, is not considered comprehensive enough by members of the mental health community because it only applies to employers and insurers that already offer mental health benefits and that have more than 50 employees.

Accusing them of failing to tell beneficiaries that they had the right to complain to the state through a toll-free hot line, the California corporations commissioner has fined 43 health plans a combined $535,000.

Pacificare paid $70,000 — for its HMO operation, a dental HMO and a mental health plan. The "800"hot line has been in operation since January 1996.

— 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.