MANAGED CARE April 1998. ©1998 Stezzi Communications

A bill before the Georgia legislature that would allow patients to sue HMOs for malpractice has created an unusual alliance between physicians and plaintiffs' lawyers, both of whom support the measure. Health plans and business groups oppose the bill, which the Georgia Chamber of Commerce calls a "huge threat" to employers.

The legislation would hold an insurer liable for harm resulting from refusal to pay for a treatment it covers but decides is not necessary in a particular case. Insurers would have to exercise "ordinary diligence," the bill says, and adhere to what it calls — but does not define — general practices and standards for health care professionals. An injury to an enrollee "resulting from a want of such ordinary diligence shall be a tort for which a recovery may be had."

Supporters of the bill argue that it would actually lead to fewer malpractice lawsuits because the threat of being sued will make managed care plans less likely to deny coverage. Opponents dismiss this argument and say that trial lawyers will be the main beneficiaries. The state HMO association says that if the bill becomes law, premiums will rise and many Georgians will lose their health coverage. Unlike a similar measure already on the books in Texas, the Georgia proposal would not require an independent review before someone could file a malpractice lawsuit.

Georgia legislators also are weighing at least 18 bills that would mandate coverage of specific conditions, including obesity, diabetes, ovarian cancer and venereal disease, as well as a proposal that would mandate minimum hospital stays of up to three days for various types of breast cancer surgery.

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.