MANAGED CARE February 1998. ©1998 Stezzi Communications

Aetna U.S. Healthcare has done an about-face on infertility benefits, after saying it would eliminate coverage for in-vitro fertilization and several other high-tech procedures. Less than a week after its announcement — which elicited outrage from physicians and from infertile couples — the HMO said it would reinstate benefits as an option in states that do not mandate coverage.

The HMO said too many women joined it to obtain coverage, then left the program.

Meanwhile:

  • Independence Blue Cross one-upped its competition by offering free eyeglasses as part of its core plan. Independent optometrists worry that many of IBC's 1.6 million members will shun them for free specs from a Blues subsidiary.
  • Following recommendations of a National Institutes of Health panel, Finger Lakes [N.Y.] Blue Cross and Blue Shield now covers NIH-approved uses of acupuncture. In November, NIH blessed acupuncture as effective for relieving post-operative dental pain, and pregnancy- and chemotherapy-induced nausea.
  • Harvard Pilgrim Health Care and United HealthCare of California now cover Cytyc's ThinPrep Pap test. The procedure may reduce the need for costly follow-up after abnormal tests.
  • Medicare risk enrollees are entitled to refer themselves for mammography screenings, says the Health Care Financing Administration. Clarifying new regulations on screening mammography, HCFA told managed care plans that they must follow Medicare fee-for-service rules, under which referrals for screenings are unnecessary.

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.