MANAGED CARE May 1997. ©1997 Stezzi Communications

Coming into compliance with the requirements of the federal Health Insurance Portability and Accountability Act (HIPAA, the Kennedy-Kassebaum bill) of 1996 is a top legislative priority in a host of state capitals. Most states will have to change their existing market reform statutes to meet the requirements of the new law or face the possible loss of state authority to enforce HIPAA mandates.

"States will spend a lot of time this year passing legislation of all different sizes and shapes to come into compliance with both the small-group and individual market requirements of the federal law," says Susan Laudicina, director of state services research for the Blue Cross and Blue Shield Association (BCBSA).

HIPAA guarantees access to health coverage for groups of 2 to 50 employees; requires health plans to guarantee renewal of all group products, including those sponsored by large employers; and limits to 12 months waiting periods imposed on pre-existing conditions diagnosed or treated within the past six months.

At least 19 states are expected to pass laws or amend existing guaranteed-issue laws for small groups, according to a recent state survey of Blue Cross and Blue Shield Plans undertaken by BCBSA. While some of these states already have laws requiring health plans to guarantee the issuance of selected products, states may interpret the law as requiring health plans to guarantee issuance of all products to small groups.

Another 16 states will probably bring their laws into compliance with HIPAA's guaranteed renewal requirement, ac- cording to the survey, and more than 20 will enact or amend statutes limiting pre-existing-condition waiting periods in the group market.

Service of HMOs In Massachusetts To Be Assessed

By naming a panel to study HMO service, Massachusetts Republican Gov. William F. Weld has temporarily defused a conflict between the state's HMOs and lawmakers who are considering dozens of regulatory bills.

Weld told the 15-member commission to report within six months, and he didn't say what he thought of the bills in the hopper. Some legislators say six months is too long to wait.

One bill with considerable backing would require responses to denial of care within 15 days, and would expand the Health Department's ability to oversee HMOs.

Patient Rights Bill Introduced In Nine States

Patient rights legislation developed by Women in Government, a nonpartisan group of women elected to or working in state government, has been introduced in nine states — Alaska, New Jersey, Texas, Colorado, Georgia, Kansas, Ohio, Oregon and Tennessee.

The only state where it has moved forward at all is Kansas, where it passed the Senate.

In its original form, the bill addresses clinical decision-making, access to personnel and facilities, choice of provider, grievance procedures and quality of care based on clinical outcomes. It requires managed care plans to give clear definitions of coverage rules for experimental treatments and timely written explanations to the patient if such treatments are not authorized by the HMO.

In addition, it prohibits "gag rules," eases some HMO rules restricting coverage of emergency care and provides patients with access to all FDA-approved drugs and devices. These provisions are not likely to appeal to health plans.

"Ensuring enrollee satisfaction and quality of care is simply good business,'' said New Jersey Republican Assemblywoman Barbara Wright, R.N., a sponsor of the legislation.

— 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.