NCQA has clarified how many plans publicly reported HEDIS data in 1998: 247 managed care organizations, representing 410 products, shared HEDIS data in Quality Compass '99.... More than 6 in 10 physicians responding to a Kaiser Family Foundation survey see health plans deny prescription-drug coverage routinely; 37 percent of those say the most recent event caused patients serious harm.... Random unannounced surveys by the Joint Commission on the Accreditation of Healthcare Organizations will soon live up to their name. Beginning in January, the Joint Commission will give hospitals and other providers no advance notice of a "surprise" visit.... According to a General Accounting Office report, many Medicare HMOs do not routinely notify members of formulary changes — leaving them to learn about them at the pharmacy counter.... Get this: More than a third of respondents told an Insurance Research Council poll that it's OK to stay home and collect workers' comp if they're still feeling a little pain — even after a physician says it's all right to return to work.
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.