MANAGED CARE March 1998. ©1998 Stezzi Communications
Washington Initiatives

The Medicaid managed care business is booming. Look for federal spending to increase from $9 billion last year to $40 billion 10 years from now — a projected growth rate of 14 percent a year.

That's the word from the Congressional Budget Office, which forecasts Medicaid expenditures of $210 billion by 2008. The main reasons: an unexpected rapid enrollment in managed care plans and higher capitation rates.

The CBO expects managed Medicaid enrollment to climb more than 10 percent a year during the next five years because of states' new flexibility to enroll Medicaid beneficiaries in managed care without waivers. One-quarter of Medicaid recipients were in capitated plans in 1996.

A word of caution: The savings we're likely to see in Medicaid managed care in the next few years won't go on forever. The new groups being enrolled by the states — children and low-cost adults — aren't where the action is. The elderly and people with disabilities make up 70 percent of Medicaid spending — and managed care models "are still in the early stages of development and may not be able to provide care for the most expensive enrollees under state plans," according to the CBO.

After 2003, the CBO says, managed Medicaid enrollment increases will taper off as states have trouble enrolling chronically ill beneficiaries.

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.