L.A. Care, a California Medicaid HMO, is rewarding physician groups that excel at preventive care. Those that exceed some HEDIS benchmarks, for instance, could receive performance bonuses.... Regence BlueShield will pay $30 million to settle suits over denial of claims for alternative therapies covered under Washington State law.... The Journal of the National Cancer Institute reports that access and outcomes for colorectal cancer patients in HMOs are comparable to those for fee-for-service enrollees.... Misuse of prescription drugs costs $177 billion a year, says a study published in the Journal of the American Pharmaceutical Association.... Forget about prescription drug reimportation. President Bush's budget guts 90 percent of funds allocated to the program Congress passed last year.... Jack Ebeler, of the Robert Wood Johnson Foundation, has succeeded the retiring Daniel Wolfson as CEO of the Alliance of Community Health Plans. ACHP is a 22-member consortium of not-for-profit health plans.... Partnerships for Quality Education is accepting grant proposals for chronic-illness management programs that encourage young physicians to learn to manage care. PQE is a collaboration between health plans and medical schools. For more information, see «http://www.pqe.org».... In Oregon, Providence Health Plan's announcement that it would remove the gatekeeper for its 300,000 enrollees brought to mind recent comments in the Los Angeles Times by George Lundberg, M.D., Medscape's editor in chief. "Managed care is basically over," he said. "Like an unembalmed corpse decomposing, dismantling managed care is going to be very messy and very smelly, and take a while."... Health information has surpassed porn as the most-searched-for subject on the Internet.

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.