For the first time, the share of workers with employer-sponsored coverage who are enrolled in HMOs or point-of-service plans is falling, according to a William M. Mercer Inc. survey. Half of all covered employees in 1997 were enrolled in HMOs or POS plans, but that dropped to 47 percent last year. PPOs' share, meanwhile, grew from 35 to 40 percent.... Another first: Inpatient days per 1,000 HMO enrollees increased in 1997 to 255, up from 246 in 1996, says Maryland-based HCIA Inc.... HMOs will fund patient care in some National Institutes of Health-sponsored clinical trials, under an agreement brokered by NIH and the American Association of Health Plans.... The Health Care Financing Administration will now give Medicare beneficiaries specific reasons for denials of claims. No longer will HCFA use the term "not medically necessary." ... The California Medical Association sued FPA Medical Management, alleging breach of fiduciary duty. CMA says the bankrupt PPM owes physicians millions in unpaid claims.... The New Mexico Medical Society is trying to figure out what to do about physicians deserting the state, attracted to bigger paychecks in Texas. The AMA says New Mexico lost an average of 27 physicians a month in 1998, up from 18 per month in 1997.
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.