MANAGED CARE May 1998. ©1998 Stezzi Communications

The Department of Health and Human Services has given approval to nine states to participate in the Children's Health Insurance Program. The program, part of the Balanced Budget Act of 1997, sets aside $24 billion over five years for states to expand health coverage for kids.

CHIP grants coverage to uninsured children whose families earn too much for Medicaid but too little to afford private coverage. More than 10 million American children — one in seven — are uninsured.

The program allows states three options: designing a new children's health insurance program, expanding current Medicaid programs or a combination of both. States may create new programs through one of three benchmark plans: the Blue Cross/Blue Shield preferred-provider organization offered by the Federal Employees Health Benefit Program, a health plan offered by the state to its employees or the HMO with the largest commercial enrollment in the state. Allocation of matching funds is based on each state's number of uninsured low-income children and regional cost differences.

As of last month, the department had approved plans in Alabama, California, Colorado, Florida, Illinois, Michigan, New York, Ohio and South Carolina. States must use this new money to cover uninsured children, not to replace existing coverage.

Fifteen other states and Puerto Rico have submitted plans to HHS. Those approved by Sept. 30 are eligible to receive some of the $4.3 billion allotted for this fiscal year.

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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.