Medstat/J.D. Power and CareData Reports recently released separate studies listing "best" health plans. In conducting their joint survey, Medstat, a health care consultancy, and J.D. Power, the marketing company, considered the views of physicians. CareData, meanwhile, sought consumer opinion when developing its list.

Medstat Group/J.D. Power & Associates

Thirty thousand physicians in 22 markets rated 150 health plans on such issues as administration, clinical autonomy and reimbursement. Curiously, while doctors reported widespread dissatisfaction with managed care, they ranked HMOs higher than fee-for-service plans in several markets. Physicians' biggest beef? More than 3 of every 4 told Medstat/J.D. Power that having to justify clinical decisions annoyed them more than anything else.

Market Top-ranked health plan**
Atlanta Kaiser Permanente
Baltimore-Washington National Capitol Area PPO
Boston Tufts Health Plan
Central Valley, California Blue Cross Prudent Buyer PPO
Chicago Blue Cross Blue Shield of Illinois (indemnity)
Cleveland-Akron Medical Mutual of Ohio (indemnity)
Dallas-Fort Worth Prudential HealthCare (indemnity)
Dayton-Springfield, Ohio *
Grand Rapids-Muskegon, Mich. Priority Health
Hartford, Conn. ConnectiCare
Houston-Galveston United HealthCare PPO
Indianapolis *
Kansas City, Mo.-Kan. *
Lansing, Mich. Blue Cross Blue Shield of Michigan (indemnity and PPO)
Los Angeles-Orange County Blue Cross Prudent Buyer PPO
Memphis Baptist & Physicians PPO
New York City United HealthCare
Northern New Jersey Oxford Health Plans
Philadelphia Personal Choice PPO
Phoenix Blue Choice
San Francisco Kaiser Permanente
Southeast Michigan Blue Cross Blue Shield of Michigan (indemnity)
* No single plan stood out in this market.
** Plans listed are HMOs unless noted. PPO = preferred-provider organization.

CareData Reports

CareData released two lists — one for commercial plans, the other for Medicare risk HMOs. The commercial survey evaluated satisfaction with 145 HMOs and point-of-service plans in 27 markets, while the Medicare inquiry reviewed 42 Medicare risk HMOs in 20 markets. Both examined members' perception of adequacy of care for specific conditions and preventive care, satisfaction with pharmacy benefits and reasons for joining and leaving plans. The top performers in markets where multiple plans were evaluated:

Top Medicare risk HMO Market Top commercial HMO Top commercial POS plan
Cigna HealthCare for Seniors Arizona Cigna HealthCare United HealthCare
Atlanta Kaiser Permanente Blue Cross/Blue Shield
NYLCare 65 Baltimore-Washington Free State Aetna U.S. Healthcare
Harvard Pilgrim First Seniority Boston Tufts Health Plan Tufts Health Plan
HealthCarePlan Senior Choice Buffalo
Dallas-Fort Worth Prudential HealthCare Prudential HealthCare
Kaiser Permanente Senior Advantage Denver Kaiser Permanente
Detroit Health Alliance Plan
Long Island Vytra Healthcare Oxford Health Plans
Milwaukee PrimeCare
AmeriHealth65 New Jersey
HIP VIP New York City Physicians Health Services Oxford Health Plans
Kaiser Permanente Senior Advantage Northern California Lifeguard United HealthCare
Keystone 65 Philadelphia Keystone Health Plan East
HealthAmerica Advantra Pittsburgh
Portland, Ore. Providence Health Plans
Seattle Group Health Cooperative/Kaiser
* South Florida AvMed Health Plan
Kaiser Permanente Senior Advantage Southern California
GHP Advantra St. Louis
† Not applicable.
* Only one plan in market evaluated.

SOURCES: THE MEDSTAT GROUP, ANN ARBOR, MICH., 1998; CAREDATA REPORTS, NEW YORK, 1998

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.