MANAGED CARE March 1998. ©1998 Stezzi Communications

The Medical Association of Georgia has sued Blue Cross Blue Shield of Georgia, saying the insurer illegally changed its contracts with physicians when it revised its reimbursement formula. Georgia Blues says it changed its payment basis from usual and customary fees to usual and customary fees physicians receive, factoring in Medicare and Medicaid, to close the gap between its indemnity and managed care reimbursements.... As 2000 draws near, plans are trying feverishly to prevent meltdown of their information systems. Kaiser Permanente signed a $23 million contract with Data Dimensions of Bellevue, Wash., to identify and correct problems. Allina Health System and Aetna U.S. Healthcare have enrolled with the Minneapolis-based Rx 2000 Solutions Institute, which provides technical assistance to health care organizations and enables them to help their suppliers and providers get in step.... Group Health Cooperative of Puget Sound offers 100 percent coverage for smoking cessation services. Its policy of having no copayment is the HMO's latest tactic in an aggressive campaign that has helped cut the prevalence of smoking among its members from 25 percent in 1985 to less than 15 percent today.... A new tool for measuring health plan quality: The Agency for Health Care Policy and Research has developed a survey HMOs and employers can give to beneficiaries to criticize plans.The idea is to give members a way to make apples-to-apples plan comparisons.

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.