MANAGED CARE March 1998. ©1998 Stezzi Communications

A large Minnesota physician group and Medica have agreed to part ways at the end of the year, forcing more than 15,000 people to choose between their health plan and their physician.

Family Health Services and Medica terminated their relationship after a dispute regarding patient autonomy. Family Health wanted to refer Medica patients only to its 15 clinics, 75 physicians and 250 specialists associated with the group. Medica countered that its Medica Choice plan gave some of those patients the right to select any provider without a referral.

Negotiations during the past year have been punctuated by Medica's resentment of a patient letter-writing campaign initiated by Family Health. Sample letters, distributed in Family Health waiting rooms, claimed Medica's X-ray and lab policies affected its ability to provide quality medical care. Family Health refused Medica's request to stop the campaign.

In Arizona, thousands of Aetna U.S. Healthcare patients are facing the same choice (if their employer offers them a choice): Side with your health plan or your doctor. A growing number of physicians in the state are refusing to re-up with the HMO, objecting to measures added to contracts as a result of Aetna's acquisition of U.S. Healthcare. The HMO is in the midst of a huge effort to standardize physician contracts.

Arizona primary care physicians are balking at seemingly tedious contract terms, such as how many chairs must be in a waiting room, or having to approve or deny all procedures recommended by specialists to whom the doctors referred patients. Physicians say this is an attempt to stifle referrals.

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.