Washington Initiatives

After more than four months of wrangling with the issue in a working group, the House GOP leadership released an outline of its package of insurance reforms and consumer protections. And it wasn't long before the proposal, developed under the guidance of Illinois Rep. Dennis Hastert, was attacked from many sides. Democrats and consumer groups said it doesn't go far enough because there are no health plan liability provisions, while businesses and insurers said it's overly laden with "government mandates." Here's what's in it:

  • Health marts, or voluntary purchasing arrangements;
  • Direct access to pediatricians and obstetrician/gynecologists as primary care doctors;
  • A ban on gag clauses in managed care contracts;
  • Coverage of emergency services if a "prudent layperson" would have considered the condition an emergency;
  • Broad disclosure requirements for health plans;
  • A $250,000 cap on malpractice punitive damages;
  • A strengthened appeals process for patients, including the right to submit denials of coverage to an independent review panel once such recourse through health plans has been exhausted.

Sample reaction: Families USA damned the outline, labeling it the "Gingrich proposal" and saying it was chock full of "recycled ideological proposals" designed to make sure no managed care legislation passes this year.

House Minority Leader Richard Gephardt of Missouri referred to the GOP outline as a "fig leaf" and predicted that it would receive a presidential veto if passed. Bill Gradison, president of the Health Insurance Association of America, argued that no congressional action would be a better alternative. The American Association of Health Plans is running television commercials aimed at discrediting this and any legislative attempt to manage managed care with the message, "When politicians play doctor, real people get hurt."

Look for the debate to continue right up to Election Day, with both sides blaming each other if no bill is enacted.

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.