Medicare+Choice, the program that was supposed to ease the elderly into managed care, is itself suffering from the uneasiness of HMOs dissatisfied with payment rates. Fifty-eight health plans will drop out of the program or reduce service territory on Jan. 1, forcing about 536,000 people either to find other managed care plans if available in their areas, or to go back to traditional Medicare. Of the 58 plans, 22 are withdrawing entirely.

This year, about 934,000 people lost their Medicare+ Choice coverage.

"We have a program where costs are outstripping reimbursement 6 to 1," Karen Ignagni, president of American Association of Health Plans, tells Congress Daily.

She adds that if not for Medicare "givebacks" that increased payments to hospitals and insurers over the last two years, regulatory changes implemented by the Bush administration, and "promises of further relief," more plans would have dropped out of Medicare +Choice.

Those "promises of further relief" must be what's fueling federal officials' optimism regarding the program. The latest data show that the number of enrollees dropped from 6.3 million in 2000 to 5.6 million by June 2001. (See "Managed Care Outlook")

Meanwhile, in the short term, the program continues to hemorrhage. The New York Times reports that the largest Medicare+Choice organization, PacifiCare, will drop 64,000 beneficiaries in California, Texas, and other states.

The paper also says that ConnectiCare will pull out of two counties in Connecticut, affecting almost 25,000 beneficiaries. Aetna U.S. Healthcare will drop 38 percent of its 277,000 Medicare beneficiaries, many of whom live in New Jersey and Pennsylvania.

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.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

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?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

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.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

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.