Maine's new drug price-control law could face legal action from the pharmaceutical industry. The Pharmaceutical Research and Manufacturers Association is keeping lawyers in Washington and in Maine, and will decide whether to sue before the end of the summer. The bill mandates stiff fines against drug companies that "exact or demand unconscionable prices," and is based on a legal precedent that forbids profiteering from food.... Now that Medicare pays HMOs on a risk-adjusted basis, are some plans being penalized for careful management? That's a possibility raised by an American Association of Health Plans policy analyst in the May/June issue of Effective Clinical Practice. W. Pete Welch, Ph.D., says that the risk-adjustment system, which is based on previous admissions, rewards plans that hospitalize liberally, while plans that take a more conservative approach are unfairly compensated, though their populations may be equally sick.... Quicker post-op discharge of bypass patients often shifts costs to nursing homes or home health care facilities, rather than encouraging overall cost-of-care reductions, according to a presentation at the American Association for Thoracic Surgery.... At the annual meeting of the American Society of Hypertension, researchers tallied failure to control hypertension at $964 million in direct and indirect costs.
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.