As expected, the Department of Health and Human Services promulgated privacy regulations after Congress failed to do so itself. The regulations, which apply to providers, plans, and billing companies, restrict the release of information without patient consent and impose fines of up to $50,000 per violation. The regulations do not supersede any state laws that are more stringent. Congress is expected to debate broader privacy rules in February.... Blue Cross Blue Shield of Tennessee has threatened to drop out of TennCare, the state's Medicaid managed care program, unless the structure of the program is changed soon. The Blues want the state to absorb losses and to place limits on the program's pharmacy benefit. Loss of the Blues would mean the end of TennCare, officials say.... Transparency or identity crisis? According to a study by the Employee Benefit Research Institute, 54 percent of HMO enrollees say they've never been in a managed care plan.
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.