MANAGED CARE April 1998. ©1998 Stezzi Communications

California Gov. Pete Wilson and legislative leaders of both political parties have defined what they want in managed care reform legislation. All agree on the need to expand enrollees' rights to appeal coverage denials.

Rather than endorse specific pending bills or proposals of a managed care reform task force that completed its work earlier this year, Wilson said any reform legislation must meet three conditions: It must safeguard or improve quality of care, should not diminish access and should be fiscally prudent and "not impose mandates that would bankrupt our health care system."

To achieve those goals, Wilson would create a new state body to oversee managed care and gather and publish standardized outcomes data. Wilson would support legislation that enhances continuity of care; addresses concerns about utilization review; requires public disclosure of formularies; improves methods of informing consumers about the results and effectiveness of treatments; gives physicians, in consultation with patients, full authority over the length of post-mastectomy hospital stays, and expands access to specialists, such as obstetrician/gynecologists. He endorses mandatory coverage of contraception, except by employers or organizations that object on religious or conscientious grounds. The governor did not address the issue of whether health plans should be liable for medical malpractice.

Wilson called on the legislature to ensure that health plans and medical groups fully disclose grievance procedures and help patients to appeal decisions and file grievances. The governor said he would support legislation requiring plans to cover second medical opinions and create independent third-party review processes for coverage denials.

Assembly Republicans proposed a series of bills that they say follows the outline of the governor's recommendations. The GOP plan would create a Department of Health Care Oversight. Unlike Democratic proposals, Republicans would not mandate coverage of specific conditions.

Assembly Democratic leaders who drafted the Family Health Care Rights Act say their proposals would require California HMOs to uphold five rights of members: the right to choose a doctor, receive appropriate treatment, get information about benefits, obtain emergency care and be assured of confidentiality.

Early compromises could come on the issues of second opinions and external review.

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.