CMS warns that the slowing economy may force it to reduce Medicare reimbursements to hospitals and doctors.... Texas Insurance Commissioner Jose Montemayor has extracted $9 million in fines and "tens of millions of dollars" in restitution to physicians from health plans accused of not complying with Texas's prompt-payment law. In New York, meanwhile, the state medical society sued six health insurers for breach of contract, claiming that they use stalling tactics to delay payments to physicians.... Louisiana officials are putting together a bare-bones plan aimed at snaring at least some of the 34,000 state employees who do not take the state's coverage choices. Worker contributions for the low-cost plan could be as low as $50 a month.... California Gov. Gray Davis has signed SB 37, which requires health plans to cover all routine medical costs associated with a patient's involvement in clinical trials for cancer treatment.... The disabled make up 17 percent of Medicaid enrollees, but use 77 percent of its behavioral health expenditures, according to the U.S. Substance Abuse and Mental Health Services Administration.... If you want a peek at the future, get to know the name Aetna HealthFund. The insurer's new product, to be offered next year, is a combination PPO and health savings account. The savings would be used for deductibles and care not covered by the PPO. It places responsibility for health care choices on the insured — a concept that employers are giving a long look.
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.