Highmark, the combined Blues plans of Western and Central Pennsylvania, recovered $3.6 million from physicians and other providers during 1997 through retrospective utilization review. Highmark's process of retrospective UR is aided by software that analyzes irregularities in claims patterns, which are then investigated. Highmark says most cases involve billing errors rather than fraud.... Kaiser Permanente lost $270 million in 1997, despite a near 20-percent increase in membership. Kaiser blamed its first-ever loss on higher prescription drug expenses and what it called its failure to foresee the need for higher premiums soon enough.... Fewer students are entering primary care residencies, thanks to what the American Academy of Family Physicians terms a "primary care backlash." AAFP says while 85 percent of primary care residencies offered this year were filled, the number of openings plugged in each of four primary care programs — family practice, pediatrics and two internal medicine residencies — was down for the first time in a decade. Given managed care's influence on specialties, medical school faculty often counsel students to consider careers in primary care. AAFP chalks up the decline to students' frustration with their perceived lack of choice.
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.
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?
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.
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.