We'll hear a lot about state-level managed care reform this year. Many states are considering bills that, in several respects, mirror aspects of consumer protection measures now under debate in Washington, D.C. Maryland and Virginia could be the next states to strengthen the rights of patients who appeal health coverage denials. And in Maryland, legislators may soon consider whether to increase the roles of physicians in the appeals process.

This session, the Maryland General Assembly is expected to consider a proposal giving the state insurance commissioner authority to resolve coverage disputes after a plan's internal appeals procedure had run its course. The commissioner would be allowed to consult third-party physicians before making a determination. The bill would apply only to HMOs — not to other types of managed care plans. A similar proposal failed to pass last year.

Maryland's bill could also contain language designed to allow nurse practitioners to contract directly with HMOs. That would overrule a decision by the insurance commissioner barring such an arrangement. Commissioner Steven Larsen ruled in November that while advanced-care nurses can perform many of the same functions as doctors, HMOs must contract with a physician, who then may hire a nurse practitioner to provide primary care. He cited state law that requires patient care to be under physician management.

Nurse practitioners counter that another state law prohibits HMOs from discriminating against providers who practice as their licenses allow. Under Medicare and Medicaid rules, nurse practitioners can operate independent of physician supervision.

In Virginia, Health Commissioner Randolph Gordon is trying to revise the state's appeals process by moving it from the insurance department to the health department. Currently, HMOs send cases for appeal to an independent medical expert hired by the plans. Under Gordon's proposal, the health department would hear the appeal, removing any appearance of a conflict of interest.

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.